Dr Mona Shroff EmOC Advan c ed Trainer Delivering Effective Lectures 1 Dr Mona Shroff .
RETAINED PLACENTA 1 Dr Mona Shroff .
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Transcript of RETAINED PLACENTA 1 Dr Mona Shroff .
Failure of placental delivery within 30 minutes after delivery of the fetus.
2Dr Mona Shroff www.obgyntoday.info
Morbid Adherence of the placenta Placenta Acreta Placenta Increta Placenta Percreta
Uterine Abnormality Constriction Ring - reforming
cervix Full bladder
3Dr Mona Shroff www.obgyntoday.info
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)
4Dr Mona Shroff www.obgyntoday.info
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.
8Dr Mona Shroff www.obgyntoday.info
Shock Postpartum haemorrhage Puerperal Sepsis Subinvolution Hysterectomy
9Dr Mona Shroff www.obgyntoday.info
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
10Dr Mona Shroff www.obgyntoday.info
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
12Dr Mona Shroff www.obgyntoday.info
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
13Dr Mona Shroff www.obgyntoday.info
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
15Dr Mona Shroff www.obgyntoday.info
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)
17Dr Mona Shroff www.obgyntoday.info
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.
18Dr Mona Shroff www.obgyntoday.info
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
21Dr Mona Shroff www.obgyntoday.info
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
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 - -
28Dr Mona Shroff www.obgyntoday.info
Follow-up OUTCOME
•SPONTANEOUS EXPULSION
•RESORPTION
•INTERVAL SURGERY –placental removal
If Intervention necessary for
- Heavy Bleeding
- Infection
- DIC
Proceed directly to TAH
29Dr Mona Shroff www.obgyntoday.info
Resort to hysterectomy
SOONER RATHER SOONER RATHER THAN LATERTHAN LATER
(especially in cases of placenta accreta when future fertility is out of concern)
30Dr Mona Shroff www.obgyntoday.info
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.
31Dr Mona Shroff www.obgyntoday.info