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8/3/2019 Ret Placenta

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RETAINED

PLACENTA

1Dr Mona Shroff www.obgyntoday.info


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Failure of placental deliverywithin 30 minutesafterdeliveryofthefetus.

2

Dr Mona Shroff www.obgyntoday.info


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Morbid Adherenceofthe placenta Placenta Acreta

Placenta Increta Placenta Percreta

Uterine Abnormality

Constriction Ring - reformingcervixFullbladder

3



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Ifthe placentaisundelivered after 30 minutesconsider: Emptyingbladder Breastfeedingornipplestimulation Changeof position - encourageanupright position

Ifbleeding:immediately Inform Anaesthetist Insertionoflargebore IV (18g)cannula Inserturinarycatheter Commence/continueoxytocininfusion 20 unitsin

1 litre/ rate 60drops per minMeasureand accuratelyrecord blood loss Prepareand transfer patienttotheatrefor

manualremovalof placenta (MROP)



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Introducingonehand intothevaginaalongcord



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Supportingthefundus whiledetachingthe placenta

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Withdrawingthehand fromtheuterus

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Observethe womancloselyuntiltheeffectof IV sedationhas wornoff.

Monitorthevitalsigns (pulse,bloodpressure,respiration)every 30minutesforthenext 6 hoursoruntilstable.

Palpatetheuterinefundustoensure

thattheuterusremainscontracted.Checkforexcessivelochia.Continueinfusionof IV fluids.Transfuseasnecessary.



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Shock

Postpartum haemorrhage Puerperal Sepsis

Subinvolution

Hysterectomy



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Umbilicalveininjectionofsalinesolutionplusoxytocinappearstobeeffectiveinthe managementofretained placenta.

Salinesolutionalone doesnotappearbemoreeffectivethanexpectantmanagement. The difficultiesinimplementingthisinterventionarerelatedtothetrainingof personnelinthetechniqueofgivinginjectionsintotheumbilicalvein.

TheWHO ReproductiveHealth Library, No 8, Oxford, 2005.The Cochrane Databaseof Systematic Reviews 2006 Issue 4



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The incidence of placenta accretahas increased 1010--foldfold in thein thepast 50 yearspast 50 years, to a currentfrequency of 1 per 2,5001 per 2,500

deliveriesdeliveries.largely as a result of the

increaseinthenumberofincreaseinthenumberofcesareansectionscesareansections



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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



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Becauseofthefactthat manyofthesecasesbecomeevidentonlyat

thefirstattempttoseparatetheplacentaat delivery,itisessentialtoattempttoidentifyantenatally

both placentaaccreta and itsattendantriskfactors,the mostcommonof whichis concurrentconcurrentplacentaplacenta previaprevia & previous CS.& previous CS.



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characterized bycharacterized by aa hypoechoichypoechoic boundaryboundary

between the placenta and the urinarybetween the placenta and the urinarybladder that represents thebladder that represents the myometriummyometriumand normaland normal retroplacentalretroplacental myometrialmyometrialvasculature.vasculature.

The normal placenta has a homogenousThe normal placenta has a homogenousappearance as well.appearance as well.

normal placenta



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LossLoss ofof the retroplacental hypoechoiczone

Progressive thinningProgressive thinning of theretroplacental hypoechoic zone

Presence of multiple placental lakesmultiple placental lakes("Swiss cheese" appearance)

Thinning of the uterineuterine serosaserosa--bladderbladderwall complexwall complex (percreta)

ElevationElevation of tissue beyond the uterineserosa (percreta)



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Dilated vascular channels with diffuselacunar flow.

Irregular vascular lakes with focallacunar flow.

Hypervascularity linking placenta tobladder.

Dilated vascular channels with pulsatilevenous flow over cervix.



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Newlyformedvessel& multiple

placentallakes



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SensitivitySensitivity SpecificitySpecificity

GRAY SCALEGRAY SCALEUSGUSG9494 7979

COLOURCOLOURDOPPLERDOPPLER

8282 9797

MRIMRI 100100 7272



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CONSERVATIVECONSERVATIVELeave placentaLeave placentaundisturbed +/undisturbed +/--M

ETHOTR

EXATEM

ETHOTR

EXATE

Uterinearteryligation UAE Internaliliacligation Oversewing of placentalbed Condom temponade B-Lynch/squaresutures Argonbeam coagulation

HYSTERECTOMYHYSTERECTOMY

Fertility desired

Patientstable

Nobleeding

Informed writtenconsent



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Intraoperative management

1.-Map exact position of placenta Make hightransverse uterine incision to avoid cutting

through placenta2.- Deliver fetus Rapid hemostasis of uterineincision (clamps, sutures)

TAH

Dguncertain Avoid TAH&Dgcertain

Definitive Rx

UAE/Ligation

Remove pl

Leave Pl in situ

UAE/ligationDo not remove pl

--PlacentaPlacenta AccretaAccreta --



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Pre/intra op EMBOLISATION

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Haemostatic multiplesquaresuture method

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1

2

3

4

5

6

B-LYNCH SUTURES

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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

--PlacentaPlacenta AccretaAccreta --



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Follow-up OUTCOME

SPONTANEOUS EXPULSIONRESORPTION

INTERVAL SURGERY placentalremoval

If Intervention necessary for- Heavy Bleeding

- Infection

-D

IC

Proceed directlyto TAH



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Resort tohysterectomy

SOONERRATHERSOONERRATHERTHAN LATERTHAN LATER(especially in cases of

placenta accretawhen future fertilityis out of concern)



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Active Mxofthird stagecanprevent&reducetheincidenceofretained placenta.

Incaseofriskfactors,alwaysconsider placentaaccreta& L/fusg/dopplerfeaturesinantenatal

period & planaccordingly.



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THANK YOUTHANK YOU


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