A pilot study on the relationship between thrombospondin-1 (THBS1) and transforming growth factor beta1 (TGFß1) in the bovine placenta during early mid-pregnancy as well as parturition with normally released and retained placenta.

During pregnancy, it is necessary to create appropriate conditions for the development of the placenta and the fetus. However, during parturition, the placenta must be separated and subsequently removed as soon as possible to not expose the female to the possibility of infection. In this study, the relationship between thrombospondin-1 (THBS1) and transforming growth factor beta1 (TGFß1) concentrations was described during bovine pregnancy (second, fourth, and sixth months; n = 3/each month), at normal parturition (NR) and parturition with fetal membrane retention (R). The presence of THBS1 and TGFß1 was confirmed in bovine placental tissues of both maternal and fetal parts. Enzyme-linked immunosorbent assay showed statistically significant differences (p < 0.05) in THBS1 concentrations (pg/mg protein) between examined parturient samples (maternal part: 5.76 ± 1.61 in R vs. 2.26 ± 1.58 in NR; fetal part: 2.62 ± 1.94 in R vs. 1.70 ± 0.23 in NR). TGFß1 concentrations (pg/mg protein) were significantly lower (p < 0.05) in the retained fetal membranes compared to the released fetal membranes in the maternal part of the placenta (26.22 ± 7.53 in NR vs. 17.80 ± 5.01 in R). The participation of THBS1 in the activation of TGFß1 in parturient bovine placental tissues leading to the normal release of fetal membranes may be suggested.

The role of ultrasound imaging in the management of partial placental retention after third trimester livebirth.

OBJECTIVES: To evaluate the impact of different ultrasound signs in the management and the role of ultrasound guidance in the surgical evacuation of partial placental tissue retention. METHODS: This is an observational cohort study and retrospective case assessment of 82 patients with clinical symptoms of partial placental retention following a third trimester singleton livebirth between January 2013 and May 2019. The ultrasound signs were recorded using a standardized protocol and the outcome of the management strategy and the use of ultrasound guidance during any surgical procedure was evaluated. RESULTS: Out of the 64 patients who had a vaginal birth, 25 (39.1%) had a manual removal of the placenta at delivery. Fifteen patients were confirmed as not having retained placental tissue and did not require further treatment. Four patients were referred after failed surgical management and four after failed conservative management. All surgical procedures were vacuum aspiration and forceps removal under continuous ultrasound guidance. A significantly lower gestational age at delivery (p < .05), shorter interval between delivery and ultrasound diagnosis (p < .05) and lower number of patients presenting with heavy bleeding was found in the conservative compared to the surgical management subgroups (p < .05). The incidence of feeding vessels was significantly (p < .05) higher in the surgical than in the conservative management subgroups and associated with increased myometrial vascularity. Six patients developed intra-uterine adhesions. In four of these cases, ultrasound examination showed a hyperechoic mass surrounded by normal myometrial vascularity and no feeding vessel. CONCLUSIONS: Ultrasound imaging accurately differentiated between patient with and without partial placental retention after third trimester livebirth. Ultrasound-guided vacuum aspiration is safe and efficient in these cases.

Carbetocin for the prevention of post-partum hemorrhage after vaginal birth: a real-world application.

OBJECTIVE: To compare maternal outcomes using Carbetocin versus Oxytocin for the active management of the third stage of labor, given a temporary national shortage of Oxytocin. METHODS: We conducted a retrospective observational study on a cohort of 866 women with vaginal deliveries at our center, >36 weeks of gestation, between November 2018 and March 2019. During the shortage period, each woman received a single slow intravenous injection of Carbetocin 100 µg at delivery of the anterior shoulder, rather than Oxytocin 5 UI, as postpartum hemorrhage prophylaxis. 146 (16.9%) patients received Carbetocin versus 720 (83.1%) receiving Oxytocin. The outcomes were rates of postpartum hemorrhage, severe postpartum hemorrhage, and placental retention. RESULTS: Incidence rates of placental retention and postpartum hemorrhage were 4.9% and 9.4% respectively. Placenta retention was significantly more likely following Carbetocin administration (adjusted odds ratio 2.5; 95% confidence interval 1.2-5.0). Postpartum hemorrhage rates were not significantly different (adjusted odds ratio 1.1; 95% confidence interval 0.6-2.1), as were severe postpartum hemorrhage rates (adjusted odds ratio 0.7; 95% confidence interval 0.2-2.2). CONCLUSION: Carbetocin is as effective as Oxytocin for postpartum hemorrhage prevention. However, we would reserve it for use after placental delivery due to the increased retention rates.

Does prior ultrasonography affect the safety of induced abortion at or after 13 weeks' gestation? A retrospective study.

INTRODUCTION: We aimed to assess whether ultrasonography prior to dilation and evacuation or medical abortion ≥13 weeks was correlated with safety. MATERIAL AND METHODS: We conducted a retrospective chart review of patients undergoing abortion ≥13 weeks at eight sites in Nepal from 2015 to 2019. RESULTS: We included 2294 women undergoing abortion ≥13 weeks (no upper gestational age limit); 593 underwent dilation and evacuation and 1701 had a medical abortion. Demographics differed by procedure for parity (19% vs 33% nulliparous, dilation and evacuation, and medical abortion) and gestational age (90% vs 52% were 13-15 weeks, dilation and evacuation, and medical abortion). Ultrasonography was performed in 81% of cases overall. Complications were rare (<1% of dilations and evacuations, 1.4% of medical abortions). The most common adverse events with dilation and evacuation were hemorrhage and cervical laceration; three women required re-aspiration. Following medical abortion, 13.5% had retained products, 12.9% with prior ultrasound and 16.3% who had not had an ultrasound. Hemorrhage and severe side-effects occurred at similarly low rates regardless of whether ultrasonography was performed. In a logistic regression model where patient characteristics and case clustering within facilities were controlled for, we found a correlation between ultrasonography and complications when retained placenta was included in the model, but there was no correlation between ultrasonography and complications when retained placenta was excluded. CONCLUSIONS: This study confirms low complication rates among women having an abortion ≥13 weeks' gestation in healthcare facilities. Settings without universal availability of ultrasound may still maintain low, comparable complication rates.

Uterine conservation in placenta accrete spectrum (PAS) disorders: A retrospective case series: Is expectant management beneficial in reducing maternal morbidity?

OBJECTIVE: To examine whether expectant management confers any benefit on operative morbidity for the management of placenta accrete spectrum (PAS) disorders. STUDY DESIGN: This was a single center retrospective cohort study at a tertiary referral center In Singapore. Women with PAS disorder between January 2006 and December 2017 were identified from the hospital register. Antenatal features, surgical factors and post-operative morbidity were compared between women having caesarean hysterectomy, those having caesarean section with placental removal and women having expectant management, defined as caesarean section with retention of placenta using the student's t and Chi square tests. The natural course, complications and preservation of fertility were examined for women having expectant management. RESULTS: Ninety women with PAS were included. The incidence of PAS was 0.064 %. Mean gestational age (GA) at diagnosis was 26.4 weeks. Elective and emergency deliveries were performed at 36.7 and 32.4 weeks respectively (p = <0.0001). Caesarean hysterectomy, Caesarean section with placenta removal and expectant management (EM) were performed in 51(56.7 %),16(17.8 %) and 23(25.6 %) women respectively. The mean blood loss (MBL) and surgical time for EM were significantly lower than those for caesarean hysterectomy 0.52 L vs 3.17 L (p < 0.0001) and 70.8 min vs 171.6 min (p < 0.0001). The advantage of lower blood loss with expectant management persisted even after blood loss at delayed hysterectomy was considered (1284.09 mL vs 3168.72 mL (p-value <0.0001)). Uterine preservation with EM was successful in 61 % (14/23) women. Although nine women (39 %) in this group needed hysterectomy most complications were minor and presented within three months. The mean follow up overall was 13 months. CONCLUSION: Traditionally caesarean hysterectomy has been the main surgical approach for PAS. Our study consolidates existing evidence for expectant management being an option for a select group of patients to avoid complications associated with hysterectomy and allow uterine preservation.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility.

Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility. This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy. One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy). Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.

Transarterial embolization for postpartum hemorrhage: lessons learned.

BACKGROUND: Although transarterial embolization (TAE) can powerfully control postpartum hemorrhage (PPH), clinical failure of TAE is not uncommon. PURPOSE: To discover whether any parameters could predict timely clinical failure of TAE, then whether a supplementary intervention could be promptly initiated. MATERIAL AND METHODS: We retrospectively analyzed 118 TAE procedures in 113 patients with PPH performed at our institution between January 2012 and May 2015. The patients were divided into the following groups: clinically successful TAE and failed TAE. Successful TAE was defined as obviation of supplementary embolization or surgical intervention for hemostasis. Gestational conditions, angiographic factors, maternal vital signs, and laboratory data were compared between the two groups. RESULTS: In total, 100 (84.8%) TAEs were clinically successful. Multivariate logistic regression analyses revealed independent risk factors of TAE clinical failure, including the requirement for augmented embolic agents, placental retention, and international normalized ratio > 1.3 ( P = 0.009, 0.001, and 0.005, respectively). The post-TAE shock index was significantly associated with TAE failure, using a cut-off value of 0.8. CONCLUSION: The discovered independent risk factors of TAE clinical failure existed before or during the TAE procedure and could not reflect the post-TAE conditions. Although the post-TAE shock index was not an independent factor, it reflected the conditions after TAE and could indicate TAE clinical failure timely.

Case with pyoderma gangrenosum abruptly emerging around the wound of cesarean section for placenta previa with placenta accrete.

A 39-year-old woman underwent emergency cesarean section (CS) due to placenta previa totalis with massive bleeding. Two major problems emerged in this patient after CS was carried out. One was partial retention of the placenta due to placenta accreta. Another major and more serious problem was pyoderma gangrenosum (PG) widely appearing at the skin of the abdomen around the CS wound. Conservative treatment was performed for the retained placenta, and it had completely disappeared by 76 days after the CS. The diagnosis of PG was promptly made in consultation with a plastic surgeon and a dermatologist when a wide ulcer emerged around the CS wound, and high-dose prednisolone was administered as treatment. At 90 days following the CS, near-complete epithelialization was achieved. This extremely rare case reflects the importance of rapid diagnosis and treatment of PG.

Intravenous carbetocin shot is superior to oxytocin infusion for placental delivery in second trimester abortion: a pilot randomized controlled trial.

OBJECTIVE: To study the efficacy of 100 µg intravenous shot of carbetocin compared to 20 IU oxytocin intravenous infusion to prevent placental retention in second trimester medical termination of pregnancy. METHODS: A double-blinded randomized controlled trial was conducted at Ain Shams University Maternity Hospital from 1 April 2013 to 30 November 2013. A total of 132 women between 14 and 24 weeks gestation indicated for termination were randomized to receive either 20 IU oxytocin infusion (n = 66) or 100 µg carbetocin shot (n = 66) after fetal expulsion. Patients were observed for time elapsed between fetal and placental expulsion, presence of placental retention and blood loss. RESULTS: Third stage was 33.4 ± 20.4 min in oxytocin group & 23.1 ± 16.8 min in carbetocin group (p = 0.002). Eight patients (12.1%) in oxytocin group had complete placental retention versus two patients (3.0%) in carbetocin group (p = 0.05). Eight patients (13.8%) received oxytocin had remnants of placenta compared to four patients (6.2%) received carbetocin (p = 0.04). Sixteen patients (24.2%) received oxytocin and six patients (9%) received carbetocin needed surgical curettage (p = 0.04). Third stage blood loss was 87.2 ± 33.7 ml in carbetocin and 206.9 ± 35.2 ml in oxytocin groups (p = 0.001). CONCLUSION: Carbetocin is superior to oxytocin infusion for management of placental delivery in second trimester abortion.

[Incidence of puerperal diseases during the first 10 days after foaling in the mare]. / Häufigkeit puerperaler Erkrankungen während der ersten 10 Tage post partum bei Stuten.

OBJECTIVE: The aim of this study was to evaluate the frequency of puerperal diseases in breeding mares in the first 10 days after birth by analysing patient data. MATERIAL AND METHODS: In a university clinic patient data of 308 breeding mares with puerperal disorders which presented within the first 10 days postpartum were evaluated over a period of 10 years. A distinction was made between diseases which were able to be diagnosed at the first examination and diseases which developed during the patient's stay in the clinic. RESULTS: A total of 21 diseases were diagnosed, with a retained placenta, lochiometra and injuries to the perineum being the most common. Many mares displayed more than one disease. Mares with a retained placenta most commonly also presented with perineal ruptures, followed by animals who also had lochiometra. Mares suffering from lochiometra commonly presented together with a retained placenta and injuries as a result of birth. Some of the mares developed further diseases. In mares with a retained placenta, this was most commonly lochiometra, followed by puerperal laminitis and thrombophlebitis. CONCLUSION AND CLINICAL RELEVANCE: The data collection shows that several diseases could relatively frequently be diagnosed in mares with puerperal disorders. Therefore, a higher percentage of further diseases must be assumed for mares which have a puerperal disease.

Protracted induction of parturition enhances placental maturation, but does not influence incidence of placental retention in cows.

As the etiopathology of retained placenta is still not resolved in cattle, we compared the effects of protracted induction of parturition (PIP) and conventional induction of parturition (SIP) on placental maturation and the occurrence of retained placenta. PIP was induced in 13 cows by administration of 1.3 mg dexamethasone im twice daily between Days 268 and 273 of gestation and 40 mg dexamethasone im on Day 274 of gestation. For SIP, 10 cows received a single injection of 40 mg dexamethasone on Day 274 of gestation. A third group (SPON, n = 11) served as a nontreated control group. Within 2 hours after birth, two placentomes were extracted from the uterus and used for assessment of placental maturation by histology and immunohistochemistry. Incidence of retained placenta was lower (P < 0.05) in group SPON (9%) compared with groups PIP (54%) and SIP (70%). Staining with Masson's trichrome and pan-cytokeratin indicated a higher degree of atrophy and flatness of the maternal crypt epithelium in cows with physiological release of fetal membranes (REL) compared with cows with retained placentae (RET). Staining with anti-caspase-3 ratified the observations as more apoptotic cells were detected in groups SPON and PIP compared with group SIP; however, data were not statistically significant. Additionally, the expressions of the potent vasodilators endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) were evaluated. Both eNOS and iNOS were only expressed in chorionic tissue. Endothelin-1 (ET-1), a major vasoconstrictor, showed positive staining in maternal crypt epithelium and in chorionic epithelium. No differences were found for iNOS and eNOS and ET-1, neither among the experimental groups nor between RET and REL cows. These findings indicate that a PIP results in increased placental maturation, but does not influence the incidence of placental retention in cows. The expression of vasoactive substances does not seem to be related to the placental separation process.

Effects of a protracted induction of parturition on the incidence of retained placenta and assessment of uterine artery blood flow as a measure of placental maturation in cattle.

The objectives of the present study were to compare the effects of a protracted and a conventional induction of parturition on the incidence of retained placenta, and to evaluate the suitability of transrectal Doppler sonography of the uterine arteries as a noninvasive method for the assessment of placental maturation. Protracted induction of labor (PIP) was precipitated in 13 cows by the administration of 1.3 mg dexamethasone im twice daily between Days 268 and 273 of gestation, and 40 mg dexamethasone im on Day 274 of gestation. For conventional induction of labor (SIP), 10 cows received 40 mg dexamethasone on Day 274 of gestation. A third group was not treated and served as control (SPON; N = 11). Blood flow volume (BFV) and resistance index in the uterine arteries were measured with Doppler sonography once a day from Day 268 of gestation until labor. After each ultrasonographic examination, blood samples for determination of steroid hormones were taken. Incidence of retained placenta was lower (P < 0.05) in group SPON (9%) compared with groups PIP (54%) and SIP (70%). In the last 7 days before parturition uterine BFV and resistance index did not change (P > 0.05) and did not differ between groups SPON, PIP, and SIP (P > 0.05). Resistance index was higher (P < 0.001) in cows with retained placenta compared with cows with released placenta, and BFV did not differ (P > 0.05) between them. Total estrogen concentrations increased by 283% (P < 0.001) in group PIP and by 60% (P < 0.05) in group SPON between Days -7 and -1 before parturition. They stayed constant (P > 0.05) until Day -2 in group SIP, but increased (P < 0.05) after the high dosage of dexamethasone within 1 day by 140%. Total estrogen levels were higher (P < 0.05) in cows with released placenta than in cows with retained placenta. In conclusion, a protracted compared with a short induction of labor results in higher estrogen levels before term, but does not affect incidence of placental retention. Neither alterations in placental maturation nor changes in steroid hormones influenced uterine blood supply. Therefore, Doppler sonography of uterine arteries is unsuitable to investigate the process of placental maturation induced by glucocorticoids in cows. Nevertheless, disturbances in the placental maturation process in cows with retained fetal membranes after parturition can be detected before parturition by a higher uterine blood flow resistance in the uterine arteries.

Relationship between the Placental Retention Time and the Reproductive Performance at the Foal Heat in Thoroughbred and a Comparison with Heavy Draft.

The aim of this study was to clarify the relationship between the placental retention time (PRT) and the reproductive performance following mating at the foal heat in Thoroughbreds. For this purpose, we interviewed 292 farmers over a period of 3 years with questionnaires evaluating foaling, expulsion of placenta and reproductive performance at the foal heat in 1,432 mares. The obtained data were later compared with a previous study of heavy draft mares. The average of the PRT of the 1,432 Thoroughbred mares was 58 ± 88 min (mean ± SD). The mean PRT of Thoroughbreds was significantly shorter than that of the148 min of heavy draft mares. The incidences of retained placenta (RP) occurring in the Thoroughbred mares were 5.2 and 4.0%, for over 3 and 4 hr after foaling, respectively. The incidence of RP over 4 hr was significantly lower than that of 25% in heavy draft mares. The pregnancy rate at foal heat of the mares in which PRT was less than 3 hr was 37%, and it significantly decreased to 11% for those with PRT of more than 3 hr. In the comparison of the reproductive performance between Thoroughbred and heavy draft mares, the pregnancy rate of Thoroughbreds dropped drastically to 10% when PRT exceeded 40, and in consequence, the pregnancy rate of Thoroughbreds was significantly lower than the 30% of heavy draft mares, which had a PRT of over 4 hr. In conclusion, the Thoroughbred mares had a low incidence of RP, however, a PRT exceeding 3 hr severely affected the reproductive performance at the foal heat.

Sífilis congênita, gêmeos natimortos e retenção placentária culminando em histerectomia: relato de caso / Congenital syphilis, stillborn twins and placental retention culminating in hysterectomy: case report

Introdução: a sífilis congênita é uma das mais incabíveis causas de morbidez e mortalidade perinatal, o que revela uma assistência pré-natal ineficaz. A infecção intra-uterina pelo Treponema pallidum pode resultar em natimorto, morte neonatal, prematuro e/ou lesões sifilíticas que conduzem adesordens como surdez, prejuízo neurológico e deformidades ósseas. É infecção congênita que persiste em destaque, mesmo com a penicilina G benzatina reduzindo em quase 98% a transmissão materno-fetal quando a mãe é tratada adequadamente. Objetivo: neste trabalho apresenta-se o caso de uma gestação gemelar que teve como desfecho a morte intra-útero dos fetos, a retenção placentária e o choque hipovolêmico, culminando em histerectomia, ocorrido na maternidade do Hospital Escola Luiz Gioseffi Jannuzzi, em Valença, Rio de Janeiro. Relato do caso: relata-se a história de uma paciente de 33 anos, de classe socioeconômica baixa, multípara, admitida no serviço em trabalho de parto prematuro, com ambos os fetos mortos intra-útero. O parto foi transpélvico, com retenção placentária e choque hipovolêmico. Efetuado o pronto-atendimento, foi realizada a histerectomia e a estabilização do quadro. O VDRL, por razão da internação, revelou positividade, com início do tratamento. A paciente permaneceu internada oito dias. Conclusão: fica evidente que a sífilis é uma moléstia com graves conseqüências para as gestantes e seus conceptos, visto que 80% das mães infectadas sem tratamento, transmitem a doença para os fetos e um grande número destes morre antes de alcançar dois anos de idade.

Introduction: congenital syphilis is one of the most inappropriate morbidity causes and perinatal mortality, revealing ineffective prenatal care. Theintra-uterine infection for the Treponema pallidum can result in stillborn, neonatal death, premature and/or syphilitic lesions that lead to disorders as deafness, neurological damage and bone deformities. It is congenital infection that persists in prominence, although penicillin benzathine G prevents in almost 98% the maternal-fetal transmission, when the mother is treated correctly. Objective: this work presents the case of a twins` gestation that ended up with the death intra-uterus of fetuses, placental retention and shock due to loss of blood, culminating in hysterectomy, witch happened at theMaternity of Hospital School Luiz Gioseffi Jannuzzi, in Valença, Rio de Janeiro. Case report: the case of a 33 year-old patient who belonged to alow socioeconomic class, with several previous childbirths is related, she was admitted in the service in premature birth work, with both fetuses deadintra-uterus. The childbirth was transpelvic, with placental retention and shock due to loss of blood. With ready-attendance done, hysterectomy andthe stabilization of the case. VDRL, in cases of internment, revealed to be positive, in the beginning of the treatment. The patient stayed eight days in the hospital. Conclusion: it is evident that syphilis is a disease with serious consequences to pregnant women and their children, since, 80% of infectedmothers without treatment, they transmit the disease to the fetuses and several of them die before reaching two years old.