POSTPARTUM RETAINED PLACENTAL FRAGMENTS DEFINED MANUAL
Prior history of retained placenta (most common).General measures (e.g., monitor vital signs, fluid therapy) and immediate manual uterine reposition.Ultrasound (confirms diagnosis in uncertain cases).Absent fundus (top of the uterus) at the periumbilical position during transabdominal palpation.Round mass (inverted uterus) protruding from the cervix or vagina.Uncontrolled cord traction and/or excessive fundal pressure during the third stage of labor.Surgical procedures (uterine balloon tamponade or packing).Active management of the third stage of labor ( see “Prevention” below).Other (e.g., p reterm delivery, maternal BMI > 40 kg/m 2).Medications lowering contractions (e.g., anesthetics, MgSO 4).Anatomical abnormalities (e.g., uterine leiomyomas).Exhausted myometrium (e.g., prolonged oxytocin use).Overdistention of the uterus (e.g., multiple pregnancies).Overview of common causes of postpartum hemorrhage A hysterectomy is often considered as a last resort in uncontrolled postpartum hemorrhage.
Treatment depends on the underlying condition and may include general measures to control blood loss and maintain adequate perfusion to vital organs, suturing of bleeding lacerations, active management of the third stage of labor like manual maneuvers to aid in placental separation, and use of uterotonic agents for uterine atony. Diagnosis is done through early recognition of clinical findings, systematic evaluation of the most common causes, and, in some cases, confirmed with ultrasound. Clinical findings are related to the amount of blood loss and can include anemia (e.g., lightheadedness, pallor) or hypovolemic shock (e.g., hypotension, tachycardia). The most significant causes of postpartum hemorrhage are uterine atony, maternal birth trauma, abnormal placental separation, velamentous cord insertion, and coagulation disorders. The onset may be within 24 hours (primary PPH) to 12 weeks postpartum (secondary PPH). PPH is generally associated with symptoms of hypovolemia.
It is the number one cause of maternal morbidity and mortality worldwide. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.Postpartum hemorrhage (PPH) is an obstetric emergency and is defined as a blood loss ≥ 1000 mL or blood loss presenting with signs or symptoms of hypovolemia within 24 hours of delivery. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion.
Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Abstract : Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18-60 mins.
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