RETAINED RETAINED PLACENTAPLACENTA

Definition: Definition: Retained placentaRetained placenta is a condition is a condition in which the placenta fails to be in which the placenta fails to be expelled within 30 minutes after expelled within 30 minutes after delivery of the fetus. The main delivery of the fetus. The main cause is cause is defective decidual defective decidual reactionreaction (decidua basalis) leading (decidua basalis) leading to absence of line of cleavage to absence of line of cleavage through the spongy layer.through the spongy layer.

INCIDENCE: INCIDENCE: About 0.5% of deliveries.About 0.5% of deliveries.

AETEIOLOGYAETEIOLOGY

1)1) Retention of separated placenta:Retention of separated placenta: Atony of the uterusAtony of the uterus with failure of with failure of

expulsion of the separated expulsion of the separated placenta.placenta.

Contraction ringContraction ring leading to hour leading to hour glass deformity of the uterus.glass deformity of the uterus.

Complete rupture of theComplete rupture of the uterusuterus with passage of the placenta to the with passage of the placenta to the peritoneal cavity.peritoneal cavity.

AETEIOLOGYAETEIOLOGY2)2) Retention of non-separated Retention of non-separated

placenta:placenta:1)1) Atony of the uterus leading to Atony of the uterus leading to

absence of shearing mechanism absence of shearing mechanism needed for placental separation.needed for placental separation.

2)2) Defective placentation in which Defective placentation in which the decidua basalis is either absent the decidua basalis is either absent or defective and so the chorionic or defective and so the chorionic villi penetrate the uterine muscles.villi penetrate the uterine muscles. Placenta accreta.Placenta accreta. Placenta increta.Placenta increta. Placenta percreta.Placenta percreta.

CLINICAL PICTURECLINICAL PICTURE Vaginal bleeding: occurs only if part or the Vaginal bleeding: occurs only if part or the

entire placenta is separated.entire placenta is separated. Uterine atony: the uterus is lax abdominally Uterine atony: the uterus is lax abdominally

and if bleeding occurs it will be severe.and if bleeding occurs it will be severe. Severe shock : Retention of placenta more Severe shock : Retention of placenta more

than 2 hours may cause shock even in absence than 2 hours may cause shock even in absence of haemorrhage (Idiopathic obstetric shock)of haemorrhage (Idiopathic obstetric shock)

Vaginal examination can detect:Vaginal examination can detect: Hour- glass contractionHour- glass contraction Absence of plane of cleavage: placenta Absence of plane of cleavage: placenta

accreta.accreta. Rupture uterus.Rupture uterus.

MANAGEMENT OF RETAINED MANAGEMENT OF RETAINED PLACENTA PLACENTA

1.1. Cases of uterine atony:Cases of uterine atony:a)a) Gentle abdominal uterine massage: Gentle abdominal uterine massage:

To stimulate uterine contraction.To stimulate uterine contraction.b)b) Give ergometrin (I.M.): Give ergometrin (I.M.): to ensure to ensure

contraction of the uterus.contraction of the uterus.c)c) Brandt-Andrews maneuver: Brandt-Andrews maneuver:

(Controlled cord traction and (Controlled cord traction and suprapubic pressure) to deliver the suprapubic pressure) to deliver the placenta.placenta.

d)d) Manual removal of the placenta:Manual removal of the placenta: under general anesthesia.under general anesthesia.

MANAGEMENT OF RETAINED MANAGEMENT OF RETAINED PLACENTA PLACENTA

2.2. Cases of contraction ring:Cases of contraction ring: Give the patient deep general Give the patient deep general anesthesia, and then do manual anesthesia, and then do manual removal of the placentaremoval of the placenta..

Manual Separation of the Manual Separation of the PlacentaPlacenta

MANAGEMENT OF RETAINED MANAGEMENT OF RETAINED PLACENTA PLACENTA

3.3. Cases of adherent placentaCases of adherent placenta In cases of simple adhesion or partial placenta In cases of simple adhesion or partial placenta

accreta; manual separation and removal of the accreta; manual separation and removal of the placenta is done.placenta is done.

In cases of placenta complete accreta either:In cases of placenta complete accreta either: Abdominal Hysterectomy: as a life saving procedure in cases Abdominal Hysterectomy: as a life saving procedure in cases

with shock and severe hemorrhage, especially multiparous with shock and severe hemorrhage, especially multiparous patients.patients.

Rarely may we attempt removing the placenta by Rarely may we attempt removing the placenta by morecellation.morecellation.

In young patients and in primigravidas; the placenta In young patients and in primigravidas; the placenta may be left in situ to undergo autolytic changes after may be left in situ to undergo autolytic changes after cutting the cord short. Antibiotics and thorough cutting the cord short. Antibiotics and thorough observation are essential. Such a management is observation are essential. Such a management is unsafe and may hazardous to many patientsunsafe and may hazardous to many patients

MANAGEMENT OF RETAINED MANAGEMENT OF RETAINED PLACENTA PLACENTA

4)4) In case of rupture uterus:In case of rupture uterus:Laparotomy is performed after Laparotomy is performed after administrating blood transfusion and administrating blood transfusion and antishock measures. Placenta is antishock measures. Placenta is removed from the peritoneal cavity and removed from the peritoneal cavity and the uterus is either repaired (in non the uterus is either repaired (in non extensive tears) to preserve the extensive tears) to preserve the patient's fertility, or removed by patient's fertility, or removed by subtotal hysterectomy, if rupture was subtotal hysterectomy, if rupture was extensive with poor patient's general extensive with poor patient's general condition.condition.

COMPLICATIONS OF RETAINED COMPLICATIONS OF RETAINED PLACENTAPLACENTA

1.1. Shock: haemorrhagic or idiopathic obstetric Shock: haemorrhagic or idiopathic obstetric shock.shock.

2.2. Postpartum hemorrhage.Postpartum hemorrhage.

3.3. Puerperal sepsisPuerperal sepsis

4.4. Subinvolution of the uterus.Subinvolution of the uterus.

5.5. Retained parts of the placenta may later form Retained parts of the placenta may later form a placental polyp and give rise to a placental polyp and give rise to choriocarcinoma.choriocarcinoma.

6.6. Complications of the method done to deliver Complications of the method done to deliver the placenta and complications of anesthesia.the placenta and complications of anesthesia.