skill lab uterine inversion..retained placenta pptx

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1. RETAINED PLACENTA UTERINE INVERSION CORD PROLAPSE Presenter :Dr. K .Bhavitha 1 st year postgraduate Moderators : Dr. K. Madhavi mam (unit chief) Dr.K . Himaja mam (Assistant professor) Dr.Y . Aruna mam (Assistant professor) Dr. Sushmitha mam(senior resident)

2. RETAINED PLACENTA

3. The placenta is said to be retained when it is not expelled out even 30minutes after the birth of the baby. Phases in expulsion of placenta Separation through the spongy layer of decidua Descent into the lower segment and vagina Finally its expulsion to outside DC DUTTA’S OBSTETRICS

4. Causes of retained placenta Poor voluntary expulsive efforts PLACENTA ADHERENS :Uterine atonicity in cases of grand multipara ,overdistension of uterus, prolonged labour , uterine malformation TRAPPED PLACENTA:Incarcerated placenta following partially or completely separated. It is due to constriction ring (hour – glass contraction) DC DUTTA’S OBSTETRICS

5. Morbid adherent placenta placenta accreta placenta increta placenta percreta - incidence is 80:15:5 respectively WILLIAMS OBSTETRICS

6. RISK FACTORS Prior history of retained placenta Poor myometrial contractility in case of pretem labour,uterine fibroids ,induced labor,multiparity Premature contraction of lower uterine segment Uterine anamolies Prior uterine scar

7. Diagnosis Diagnosis is made by an arbitary time spent following delivery of the baby [60 min following delivery according to WHO] Dangers Haemorrhage Shock is due to a. Blood loss b. Retained more than one hour c. Frequent attempts of abdominal manipulation 3. Puerperal sepsis 4. Risk of its recurrence in next pregnancy DC DUTTA’S OBSTETRICS

8. Management Period of watchful expectancy Watch for bleeding Note the signs of separation of placenta The bladder should be emptied using a rubber catheter Any bleeding during the period should be managed. Placenta is separated and retained - To express the placenta out by controlled cord traction. - - Unseparated retained placenta - Manual removal of placenta under G.A DC DUTTA’S OBSTETRICS

9. Management of unforseen complications during manual removal 1. Hour glass contraction – placenta either inseparated or separated – partially or completely, may be trapped by a localised contraction of circular muscles of the uterus. This ring should be made to relax by . Deepening the plane of plane of anaesthesia (halothane) Separate placenta from above downwards to minimize bleeding DC DUTTA’S OBSTETRICS

10. Morbid adherent placenta Manual removal Management of complicated retained placenta 1. Retained placenta with shock but no haemorrhage To treat shock Manual removal of placenta when the condition improves. 2. Retained placenta with haemorrhage To assess the amount blood loss and to replace the lost blood Manual removal DC DUTTA’S OBSTETRICS

11. 3 . Retained placenta with sepsis Intrauterine swabs are taken for culture Administer broad spectrum antibiotic Blood transfusion 4. Retained placenta with an episiotomy wound The bleeding points of the episiotomy wound are to be secured by artery forceps Manual removal of placenta followed by repair of episiotomy wound.

12. Manual Removal of the Placenta under anesthesia Anesthesia and antibiotic cover given One hand is inserted through the vagina and into the uterine cavity. Insert the side of your hand in between the placenta and the uterus. Using the side of your hand, sweep the placenta off the uterus. The abdominal hand exerts firm counter pressure After most of the placenta has been swept off the uterus, curl your fingers around the bulk of the placenta and exert gentle downward and outward traction. Then pull the placenta through the cervix . DC DUTTA’S OBSTETRICS

13. Birth canal is checked for tears Placenta checked to see its completeness Continue oxytocin drip to prevent uterine atony

14. RISKS OF MANUAL REMOVAL Infection Sepsis Bleeding Uterine rupture

15. Placenta Accreta (morbid adherent placenta) The placenta is directly anchored to the myometrium partially or completely without any intervening decidua. Probable cause is defective decidual formation [absence of decidua basalis or nitabuchs layer] The condition is usually associated when the placenta happens to be implanted in lower segment

16. Types of adherent placenta Placenta accreta: Placental villi are attached to the myometrium placenta increta: Trophoblast has invaded the myometrium Placenta percreta : Villi have penetrated myometrium to reach or to cross the serosa

17. RISK FACTORS prior c section Placenta previa Prior uterine surgery /manual removal of placenta/ synecolysis /myomectomy WILLIAMS OBSTETRICS uterus Risk percentage unscarred 3 1 prior section 11 2 prior 40 > /= 4 prior 67

18. Diagnosis ultrasound features Loss of normal hypoechoic retroplacental myometrial zone Placental lakes /lacunae Disruption of bladder serosa interphase Bridging vessels from placenta to bladder serosa interface Placental bulge that pushes outward and distorts uterine contour WILLIAMS OBSTETRICS

19. Diagnosis in labour Partial separation presents with bleeding in the third stage of labour A completely adherent placenta does not give rise to bleeding and should be suspected when there is a well-contracted uterus with a non-separated, retained placenta without bleeding

20. TREATMENT If diagnosed postpartum Single cotyledon: Removed from the uterine wall and excessive bleeding may be controlled with oxytocics . Entire placenta or a large part of the placental bed: Prompt hysterectomy under antibiotic cover. Preserve her fertility: The placenta may be left in situ after counselling the woman and explaining to her the possible risk of bleeding/infection and the possible need for an emergency hysterectomy and treated with methotrexate therapy. While on methotrexate(acts by inhibiting trophoblastic cells) the woman should be monitored with weekly USG for the size of the placenta, Doppler of the placental site for vascularity, serial β- hCG measurements, investigations for evidence of infection and hematological parameters for evidence of methotrexate toxicity.

21. IF DIAGNOSED ANTENATALLY Tertiary care centre + multidisciplinary approach Experienced senior obstetrician and anesthetic staff A blood bank to support massive transfusion The pre-delivery hematocrit should be raised to 30. When placenta accreta is suspected or present, serial USG should be done every 3–4 weeks to know the depth of placental invasion Delivery timing – individualised: 34–35 weeks in adherent placenta and 36–37 weeks in uncomplicated placenta previa

22. Counselled regarding hysterectomy, profuse hemorrhage , transfusion, increased complications and maternal death General anesthesia or a continuous epidural can be given Surgical technique: A classical cesarean - the cord is ligated and cut as close to the placenta as possible Oxytocics are given No attempt should be made to remove the placenta A cesarean hysterectomy should be carried out with the placenta

23. CONSERVATIVE METHODS Risks of severe sepsis and torrential hemorrhage . Strong fertility desire: interventional radiology and uterine artery embolisation can be carried out. Arterial ligation to reduce the blood flow to the placental site can also be undertaken. Systemic/ intraumbilical administration of methotrexate can be used. All women managed conservatively should be carefully monitored for regression and autolysis of the placenta and evidence of impending sepsis. All preparations should be available for an emergency hysterectomy.

24. sequalae of conservative management Risk of severe sepsis and hemorrhage Secondary PPH Subinvolution of uterus Placental polyp formation MUDALIAR AND MENON’S

25. Placenta percreta Hysterectomy along with partial cystectomy is performed DC DUTTA’S OBSTETRICS

26. INVERSION OF UTERUS

27. INTRODUCTION 1 in 2000 deliveries Inversion of the uterus refers to the uterus being turned inside out- may occur immediately after delivery. Caused either by pressure on the uterus from above or by traction on the umbilical cord from below in the presence of an atonic uterus and a soft, dilated cervical os .

28. RISK FACTORS Injudicious attempts at the removal of the placenta Excessive cord traction with an unseparated placenta Fundal pressure and squeezing the placenta down Placenta accreta Short umbilical cord When the woman is on tocolysis and the uterus is relaxed Manual removal of the placenta Uterine malformations Prolonged labour Uterus overdistended Fundal implantation of the placenta

29. CLASSIFICATION BASED ON DEGREE OF INVERSION 1 ST DEGREE –Dimpling of fundus ,lies above internal os 2 ND DEGREE – Fundus passes through cervix but lies inside vagina 3 RD DEGREE- Fundus outside vulva

30. BASED ON TIMING ACUTE – within 24 hours of delivery SUBACUTE – Within 24 hours to 4 weeks of delivery CHRONIC –Beyond 4 weeks or in non pregnant stage

31. SYMPTOMS AND SIGNS Acute puerperal inversion of the uterus: pain, hemorrhage or sudden collapse - hemorrhagic or neurogenic. If the placenta is still attached to the inverted fundus and appears at the vulval introitus, it can be easily mistaken for retained placenta; in such cases, inversion will be missed. Per abdomen: May not be able to feel the uterine fundus. Alternatively, it may be felt as a dimple.

32. The inverted uterus: Dark red, fleshy mass at the introitus. If the placenta is still attached, it should be left in place until reduction. On vaginal examination, the cervical os cannot be palpated. Differential diagnosis: Polyps or prolapse of the uterus When in doubt, emergency USG - locate the fundus of the uterus.  

33. MANAGEMENT Prompt recognition and treatment are crucial. Resuscitation immediately with intravenous fluids till the arrival of cross matched blood The placenta should not be detached until the uterus is replaced and contracted. The uterus should be replaced immediately under anesthesia and tocolytics to relax the constriction ring Prophylactic broad spectrum antibiotics are given

34. Manual replacement[Johnson’s method] Principle: the portion that comes down last should be replaced firs t. Cervical canal is the last to come down, and it should be replaced first, and the fundal portion should be replaced last. The protruding fundus is held with the palm of the hand and the fingers are directed towards the posterior fornix; steady upward pressure is applied. In the majority of cases, during the replacement of an inverted uterus, the fundal portion flops back into position once the greater part of the inverted uterus has been replaced. The other hand should be placed on the abdomen to support the uterus as it is being replaced

35. Tocolytic agents such as ritodrine , magnesium sulfate,terbutaline can be used to relax the uterus during manual repositioning Once the correction is achieved ,oxytocic drugs are given to assist uterine contraction and to prevent recurrence If the placenta is attached to the fundus ,it is removed after repositioning the inverted uterus If removed prior to repositioning ,major hemorrhage can occur ,which may not be controllable

36. Tocolytic agents such as ritodrine, magnesium sulphate or ter

37. Uterine inversion is more common in caesarean section Placenta is to be removed before correcting inversion as the bulk of uterus and placenta may prevent reduction of uterus through the incision

38. O’SULLIVANS HYDROSTATIC METHOD The woman is placed in the Trendelenburg position. A sterile douche system is prepared using warmed normal saline [about 3 to 5 liters] and an ordinary IV administration set. The nozzle of the douche is placed in the posterior fornix. At the same time, the labia are sealed over the nozzle with the other hand. An assistant is asked to turn on the douche with full pressure. In this method, water distends the posterior fornix of the vagina gradually so that it stretches - the circumference of the orifice increases - relieves cervical constriction and results in the correction of the inversion.

39. SURGICAL METHODS Huntington’s method: Allis forceps are placed at the dimple of the inverted fundus and gentle upward traction is applied. The forceps are further advanced till the fundus is repositioned. Haultain’s technique: If the constriction ring still prohibits repositioning, it is incised posteriorly with a longitudinal incision. The fundus is reposited and the uterus is repaired in two layers.posterior incision is preffered to prevent accidental bladder injury After repositioning, the fundus should be massaged carefully, uterine contractions promoted, and the patient treated for shock and collapse. Appropriate antibiotics should be given. oxytocics continued for 24 hours to prevent recurrence

40. Prevention One should wait for signs of placental separation before attempting placental removal by controlled cord traction. Fundal pressure should not be applied.

41. CHRONIC PUERPERAL INVERSION In some cases, inversion may not be recognised at the time of its occurrence and the diagnosis is made at a later date. The woman suffers repeated hemorrhage and a slight rise in temperature. The exposed endometrium has a granular, shaggy appearance due to chronic congestion and infection, particularly over the placental site. Vaginal examination: Globular swelling, with the soft, thickened endometrium and a hyperemic appearance.

42. Diagnosis Differentiate inversion from prolapse of the uterus: Globular nature of the mass, with its velvety surface, the absence of the external os at its lower end, and the presence of the ring of the dilated cervical canal above the mass. A fibroid polyp: On bimanual examination, the fundus of the uterus is palpable in its normal position in case of a fibroid polyp. A careful vaginal examination with the finger introduced into the cervical canal, the pedicle of the fibroid polyp may be palpable.

43. Management The immediate treatment is to combat infection with antibiotics. Later, under an anesthetic to replace the inverted uterus. If unsuccessful, Spinelli’s or Haultain’s surgery may be performed.

44. UMBILICAL CORD PROLAPSE AND PRESENTATION

45. Cord prolapse is a condition in which the umbilical cord comes out through the cervical os , either in advance or along with the presenting part The fetal outcome is poor as the cord is compressed between the fetus and the maternal bony pelvis Incidence: 0.5% Malpresentations account for 50% of cases of cord prolapse Risk of cord prolapse is 7-15% with transverse lie and 4-6% with breech presentation

46. Overt cord prolapse: The cord prolapse occurs in advance of the presenting part after the rupture of the membranes and the cord is either palpable within the vagina or protrudes through the vagina . Occult cord prolapse: The cord is seen by the side of the fetal presenting part after the rupture of the membranes but not below it. Suspected whenever there are CTG abnormalities . Cord presentation: The membranes are intact, and through them,the cord is felt either below or along with the presenting part .

47. ETIOLOGY Spontaneous cord prolapse: Cephalopelvic disproportion Malpresentations Multiple gestation Rupture of membranes in polyhydramnios Cord abnormalities Preterm delivery/growth restriction/preterm PROM

48. Iatrogenic cord prolapse Amniotomy, especially when the fetal presenting part is not engaged External cephalic version During amnioinfusion or amnioreduction While applying forceps or vacuum

49. CORD PROLAPSE Diagnosis: Cord may be palpable within the vagina or may be visible outside the introitus. Often accompanied by severe, sudden fetal heart rate decelerations, prolonged bradycardia and variable decelerations. Other palpable soft masses in the vagina such as the fetal limb, caput or fetal intestines may be confused with the umbilical cord .

50. MANAGEMENT Diagnosis to delivery interval greater than 10 minutes is independently associated with adverse neonatal outcome Check for pulsations of cord If Pulsations absent confirm by doppler or ultrasound manage based on presentation ,uterine activity ,cervical status

51. If fetus is alive Patient is in second stage of labour ,quick delivery can be achieved by forceps or ventouse If patient is in first stage of labour or in second stage when instrumental delivery fails ,immediate caesarean section must e resorted If fetal heart rate pattern is suspicious a category 1 caesarean section should be performed aiming to deliver baby in 30 minutes

52. Measures prior to caesarean section Call for help Inform anesthetist , ot staff, pediatrician Prepare for emergency caesarean section Release pressure over cord – Manual elevation of presenting part Vago method-filling bladder with 500 to 700 ml of warm saline which distends bladder and relieves pressure on presenting part Maternal positioning –knee chest position /Trendelenburg position Careful handling of cord Wrap cord in warm sterile saline soaked gauge to prevent spasm

53. Oxygen administration Tocolysis To reduce uterine contractions and prevent further compressions Terbutaline 0.25 mg subcutaneously or Isoxsuprine 0.5 mg IV slowly Fetal monitoring

54. Prevention: Women with transverse and oblique lie may be hospitalised by 37 weeks . Continuous CTG monitoring . A high risk of cord prolapse should be counselled and advised to report immediately if the membrane ruptures or there is reduced fetal movement . Following the rupture of membranes in labour, immediate vaginal examination should be performed to rule out cord prolapse .

55. Unexplained fetal distress in labour - cord prolapse should be looked for. If the head is not engaged but amniotomy has to be undertaken, then a controlled rupture of membrane is performed, which should allow a slow release of fluid rather than sudden decompression using a thin hypodermic needle While performing procedures such as catheter placement or scalp electrode placement , care should be taken not to elevate the fetal head Cervical balloon catheters elevate the fetal head out of the pelvis, as a result of which, there is a risk of cord prolapse