Association between first-trimester ultrasound imaging of eccentric implantation and retained placenta.

OBJECTIVES: To evaluate first-trimester ultrasound imaging of eccentric implantation in predicting the probability of retained placenta. METHODS: A total of 61 cases with gestational sac eccentrically implanted in first-trimester ultrasound imaging was selected. Demographic and obstetric data were collected through data extraction of the electronic medical record at the time of delivery admission. Baseline characteristics (including age, gestational age of first-trimester ultrasound, size of gestational sac, gestational age of delivery), delivery outcomes (mode of delivery, retained placenta or placental fragments, blood loss, postpartum hemorrhage and postpartum ultrasound imaging) were collected and analyzed. RESULTS: The risk difference for a woman with eccentric implantation to have a retained placenta was -0.18 (95% CI -0.28 to -0.08, p = 0.000) and the incidence of retained placenta in the study group was higher than in the control group (18% vs. 0%, p = 0.006). First-trimester ultrasound imaging of eccentric implantation was also found to be an independent risk factor for the incidence of inhomogeneous mass in postpartum ultrasound imaging (27.9% vs. 10.8%, adjusted OR 0.19, 95% CI 0.05 to 0.79, p = 0.012). Though 2 cases in the study group suffered postpartum hemorrhage, the risk difference for a woman with eccentric implantation to suffer postpartum hemorrhage was -0.03 (95% CI -0.08 to -0.01, not significant) and eccentric implantation did not increase postpartum hemorrhage rates (3.3% vs. 0%, not significant). CONCLUSIONS: First-trimester ultrasound imaging of eccentric implantation was associated with an increased risk of retained placenta and inhomogeneous mass in postpartum ultrasound imaging.

Racial and ethnic disparities in the incidence, healthcare utilization, and outcomes of retained placenta among delivery hospitalizations in the United States, 2016-2019.

BACKGROUND: Retained placenta is a concern during labor and delivery. However, recent data regarding the profiles of retained placenta are scarce, especially nationwide and in minority populations. This study aimed to investigate the recent incidence of retained placenta and its associated outcomes. METHODS: We retrospectively analyzed an American population-based data from the National Inpatient Sample (NIS) 2016-2019. The outcomes of interest included the incidence of retained placenta, in-hospital mortality, length of hospital stay, and hospitalization costs. We estimated the incidence for retained placenta overall and by racial and ethnic subgroups, utilizing survey weights standardized for each subgroup. Multivariable linear or logistic regression models were employed in our study to investigate the associations between retained placenta and the impact of in-hospital mortality, duration of stay, and hospitalization expenditures for the entire population and further stratified by race and ethnicity, adjusting for potential confounders. RESULTS: Of the 13,848,131 deliveries, there were 108,035 (or 0.78%) birthing persons were identified as having retained placentas. Over time, the incidence of retained placenta increased from 730 per 100,000 (0.73%) in 2016 to 856 per 100,000 (0.86%) in 2019. Native American mothers have the highest rate of retained placenta, with a prevalence almost twice that of the general population, reaching 1,434 cases per 100,000 (1.43%). After adjusting for confounding factors, Native American mothers were more likely to have retained placenta (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.35-1.81), whereas Black (OR, 0.92; 95% CI, 0.88-0.97) and Hispanic mothers (OR, 0.84; 95% CI, 0.80-0.89) were significantly less likely to have retained placenta than White mothers. Furthermore, those who delivered with a retained placenta were significantly associated with higher in-hospital mortality, a longer duration of stay, and hospitalization expenditures, which were disproportionately varied by maternal race and ethnicity. CONCLUSIONS: The incidence of retained placenta among people undergoing vaginal delivery is exhibiting an upward trend over time, with notable variations observed across different ethnic groups by unclear mechanisms. The ramifications of these findings have the potential to impact the clinical management of maternal health care and the creation of health policies, specifically in relation to the Native American birth population.

Retained products of conception - a retrospective analysis of 200 cases of surgical procedures for the diagnosis of residua postpartum.

OBJECTIVES: Postpartum retained products of conception are a relatively rare diagnosis occurring in approximately 1% of cases after spontaneous deliveries and abortions. The most common clinical signs are bleeding and abdominal pain. The diagnosis is based on clinical signs and ultrasound examination. MATERIAL AND METHODS: Retrospective analysis of 200 surgical procedures for the diagnosis of residua postpartum obtained in 64 months. We correlated the method and accuracy of diagnosis with definitive histological findings. RESULTS: During 64 months, we performed 23 412 deliveries. The frequency of procedures for diagnosis of retained products of conception (RPOC) was 0.85%. Most (73.5%) of the D&C were performed within six weeks of delivery. Histologically, the correct diagnosis was confirmed in 62% (chorion + amniotic envelope). There was interestingly lower concordance of histologically confirmed RPOC in post-CS patients (only 42%). In women after spontaneous delivery of the placenta, the diagnosis of RPOC was confirmed by histological correlate in 63%, and the highest concordance occurred in women after manual removal of the placenta in 75%. CONCLUSIONS: Concordance with histological findings of chorion or amnion was seen in 62% of cases; this means that the incidence rate in our study was around 0.53%. The lowest concordance is after CS deliveries, 42%. D&C for RPOC should be performed after adequate clinical evaluation and in the knowledge of 38% false positivity. There is certainly more space for a conservative approach under appropriate clinical conditions, especially in patients after CS.

Risk factors for retained placenta in a first pregnancy-A clinical trial.

OBJECTIVE: To evaluate potential risk factors for retained placenta in a first pregnancy. METHOD: This retrospective case-control study included all primigravida with a singleton, live, vaginal birth at 24 weeks or later, at a tertiary hospital, 2014-2020. The cohort was divided into those with retained placenta versus controls. Retained placenta was defined as the need for manual extraction of the placenta or portions of it, immediately postpartum. Maternal and delivery characteristics, and obstetric and neonatal adverse outcomes, were compared between groups. Multivariable regression was performed to reveal potential risk factors for retained placenta. RESULTS: Among 10 796 women, 435 (4.0%) had retained placenta and 10 361 (96.0%) controls did not. Multivariable logistic regression revealed nine potential risk factors for retained placenta: abruption (adjusted odds ratio [aOR] 3.58, 95% confidence interval [CI] 2.36-5.43), hypertensive disorders (aOR 1.74, 95% CI 1.17-2.57), prematurity (<37 weeks, aOR 1.63, 95% CI 1.13-2.35), maternal age older than 30 years (aOR 1.55, 95% CI 1.27-1.90), intrapartum fever (aOR 1.48, 95% CI 1.03-2.11), lateral placentation (aOR 1.39, 95% CI 1.01-1.91), oxytocin administration (aOR 1.39, 95% CI 1.11-1.74), diabetes mellitus (aOR 1.35, 95% CI 1.01-1.79), and female fetus (aOR 1.26, 95% CI 1.03-1.53). CONCLUSION: Retained placentas in first deliveries are associated with obstetric risk factors, some of which could be related to abnormal placentation.

Increased incidence of reproductive disorders associated with short gestation length in Holstein dairy cows.

The purpose of the current study was to investigate the effect of gestation length (GL) on productive performance, and the incidence of calving and reproductive diseases in Holstein dairy cows. In total, 3800 Holstein singleton cows (2000 heifers and 1800 cows) from two commercial dairy farms were used. The average gestation length for 3800 cows was 276 ± 6 d. Cows with GL shorter or longer than 3 SD from the mean were removed and considered outliers. This process led to the elimination of 20 cows from the 3800 cows enrolled in the study. Therefore, 3780 cows (1994 heifers and 1786 cows) remained for data analysis, with a range of GL between 258 and 294 d. The mean of GL for the remaining 3780 cows in the study was 276 ± 5 d, which were classified as short (SGL; more than 1SD less than the population mean, mean = 267, range 258-270 d), average (AGL; population mean ± 1SD, mean = 276, range 271-281 d), and long (LGL; more than 1SD greater than the population mean, mean = 284, range 282-294 d) gestation length. In primiparous cows, the incidence of stillbirth, retained placenta, metritis, and clinical endometritis were higher in the SGL cows than in the AGL cows, but the incidence of dystocia was similar across groups. In multiparous cows, the incidence of dystocia, retained placenta, and metritis were higher in the SGL cows than in the AGL cows, and the incidence of stillbirth was higher in the SGL and LGL cows than in the AGL cows. In primiparous cows, milk yield was not different across groups. However, in multiparous cows, the SGL cows had lower milk yield than the AGL cows. In primiparous cows, the SGL cows had lower colostrum production than the AGL cows, but in multiparous cows, there was no difference in colostrum production across groups. In general, cows with either short or long gestation length had impaired health and production, but this impact was more pronounced in cows with short gestation length.

Bovine anaplasmosis as a risk factor for retained placenta, mastitis, and abomasal displacement in dairy cattle.

This study aimed to evaluate the frequency of IgG antibodies against A. marginale, the occurrence of this bacterium by qPCR, and the effect of bovine anaplasmosis as a risk factor for clinical cases of retained placenta, mastitis, and abomasal displacement in dairy cattle. For that 179 Holstein cows out of three dairy herds, in the municipality of Sertão, Rio Grande do Sul, Brazil. These cows were on farms that were vulnerable to risk factors that are crucial to susceptibility among these animals to this intracellular hemoparasite. The mean seropositivity for A. marginale from the periods evaluated was 54% on farm A, 69.4% on farm B, and 27.3% on farm C. Molecular diagnosis was performed with qPCR and the mean positivity for A. marginale among the cows on farms A, B, and C in December 2017 was 34.6% (67/179). Infected animals showed clinical cases of retained placenta (6.1%), mastitis (6.1%), and abomasal displacement (0.5%). The association between positivity for anaplasmosis and these clinical cases was assessed through the odds ratio. Our results show that females with a positive qPCR assay for A. marginale had 52.48 times increased probability (OR) to develop clinical cases of retained placenta and mastitis (P < 0.001). These clinical cases negatively impact the productivity of positive females. Thus, implementing preventive and prophylactic control measures to ensure the sanitary quality of the herds is needed to avoid losses due to morbidity and mortality and diminish the economic losses suffered by farmers.

Potential prognostic markers of retained placenta in dairy cows identified by plasma metabolomics coupled with clinical laboratory indicators.

The complex etiopathology of retained placenta (RP) and hazards associated with it has made it crucial for researchers and clinical veterinarians to study pathogenesis, early-warning diagnosis, and treatment. This study aimed to screen the potential prognostic markers of RP in dairy cows using plasma metabolomics coupled with clinical laboratory indicators. Blood samples were collected from 260 dairy cows at 21, 14, 7, and 0 days before parturition and 7, 14, and 21 days after parturition. Consequently, 10 healthy cows and 10 cows with RP with similar parity, body condition score, and age were included in the study. The changes in clinical laboratory indicators of the enrolled cows from 21 before parturition to 21 days after parturition were assessed. After initial overview of the multivariate statistical data using PCA analysis, the data were subjected to orthogonal partial least-squares discriminant analysis. Compared with cows with RP at 7 days before parturition, the levels of endothelin and 6-keto-prostaglandin F1α were increased in healthy cows, while the level of estradiol and progesterone decreased. Adenine dinucleotide phosphate, hypoxanthine, guanine dinucleotide phosphate, inosine monophosphate, and L-arginine were revealed as potential prognostic markers of cows with RP at 7 days before parturition involved in the regulation of taste transduction, purine and glutathione metabolism, and autophagy. The best period for the early-warning diagnosis of RP in dairy cows is 7 days before parturition, and purine metabolism and autophagy may play a vital role in the occurrence and development of RP in dairy cows.

Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study.

OBJECTIVE: To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery. METHODS: With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967-2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes. RESULT: We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78-0.82), atony (aOR 0.92, 95% CI: 0.90-0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95-0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5-13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3-7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5-6.4), atony (aOR: 4.0, 95% CI: 3.8-4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5-4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1-2.3). CONCLUSION: Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.

Placental cord drainage and its outcomes at third stage of labor: a randomized controlled trial.

BACKGROUND: The third stage of labor begins with the baby's birth and ends with the expulsion of the placenta and embryonic membranes. The prolongation of the third stage of labor, placental retention, subsequent issues such as postpartum hemorrhage, and manual removal of the placenta have adverse outcomes, which eventually affect the positive experience of delivery. The present study aimed to assess the effect of placental cord drainage on the duration of the third stage of labor and to clarify its effects on postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta. METHODS: This study was a parallel-group randomized trial. Four hundred women in the third stage of labor after vaginal delivery were randomized into the drainage (placenta drainage, n = 200) and the control groups (no placenta drainage, n = 200). In both groups, the third stage of labor was performed with the active method, and the placenta was removed using the Brandt-Andrews maneuver with maternal pushing. The duration of the third stage was compared between the two groups as the primary outcome. Also, the incidence of postpartum hemorrhage, retained placenta, and manual removal of placenta was compared. RESULTS: In all, 175 women in the drainage group and 165 women in the control group were included in the analysis. The third stage of labor was significantly shorter after placental cord drainage. The mean duration of the third stage was 7.09 ± 1.01 minutes in the drainage group, and it was 10.43 ± 3.20 minutes in the control group (P < 0.001). Postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta in the drainage group was significantly less than in the control group. CONCLUSION: Placental cord drainage is a simple and non-invasive method of reducing the duration of the third stage of labor. This method does not increase postpartum complications. TRIAL REGISTRATION: IRCT2014041917341N1 , retrospectively registered at 15. 10. 2017.

Impact of waterbirth on post-partum hemorrhage, genital trauma, retained placenta and shoulder dystocia: A systematic review and meta-analysis.

BACKGROUND: There is insufficient high-quality evidence to either support or discourage water birth (WB). OBJECTIVES: To examine different maternal complications of WB compared to standard land birth (LB). The primary outcomes were postpartum hemorrhage and genital trauma. The secondary outcome included the risk of retained placenta and shoulder dystocia. METHODS: We searched the electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO. In addition, we searched in Google Scholar and ClinicalTrials.gov. The pooled results were used to evaluate the association between WB and obstetric outcomes. This systematic review (SR) was reported according to PRISMA statement 2020. Statistical meta-analyses were performed using Cochrane RevMan version 5.4 software (http://www.cochrane.org). RESULTS: This systematic review included 22 studies (20 observational studies and 2 RCT). The pooled results showed lower risk of major PPH compared to the LB group (OR = 0.76, 95% CI: 0.66-0.89), no significant difference (OR: 0.94, 95% CI: 0.50-1.78) in the incidence of minor PPH (500-1000 mL blood loss) between WB and LB, no significant difference in the rate of third- and fourth-degree lacerations (OR = 0.87, 95% CI: 0.71-1.07) and in the incidence of retained placenta (OR = 1.30, 95% CI: 0.50-3,35), fewer shoulder dystocia for WB (OR = 0.42, 95% CI: 0.35-0.50). However, compared with the LB group, the rate of first-second-degree tears in the WB group increased by 45% (OR = 1.45, 95% CI: 1.16-1.81). CONCLUSION: We support ACOG guidelines recommendation for further RCT to assess the impact of water immersion during delivery on maternal outcomes.

Genetic analysis of retained placenta and its association with reproductive disorder, production, and fertility traits of Iranian Holstein dairy cows.

To facilitate breeding for improved resistance to the reproductive disorder of retained placenta (RP), genetic parameters were estimated for RP and its genetic correlation with other reproductive disorders as well as with production and fertility traits of Iranian Holstein dairy cows. Data were 154,048 lactation records collected between 2011 and 2018 from 59,610 Holstein dairy cows in 9 Iranian herds. Other reproductive disorders included dystocia, stillbirth, and twinning. Fertility records were available for days from calving to first service (DFS), days open (DO), number of inseminations per conception (NIC), and success of first insemination (SFI). Genetic parameters for RP were estimated using univariate linear and logistic animal models with ASREML software. The univariate linear animal model was used to implement bivariate analysis to investigate potential genetic correlations of RP with other reproductive disorders and with production and fertility traits. Heritability estimates for RP were low from both linear (0.031) and logistic (0.092) animal models. Estimated genetic correlations with RP were -0.04 for twinning, 0.32 for stillbirth, and 0.34 for dystocia, which indicates that selection against RP could indirectly select against dystocia and stillbirth. Estimated genetic correlations between RP and production traits (milk, fat, and protein yields) at 100, 200, and 305 d in milk ranged from -0.12 to -0.29; the greatest correlation (-0.29) was for the first 100 d in milk. A moderate positive genetic correlation (0.25) was found for RP and DO, DFS, and NIC, whereas a low negative genetic correlation (-0.09) was found between RP and SFI. The pedigree-based genetic analysis of RP showed that this trait has a low heritability, is linked to other reproductive disorders, and generally has an unfavorable relationship with production and fertility traits. Selection against RP can reduce the incidence of reproductive disorders and improve fertility and production traits.

Risk factors for postpartum hemorrhage in patients with retained placenta: building a predict model.

OBJECTIVES: Among patients with placenta retention, the risk factors of massive blood loss remain unclear. In this study, a secondary data analysis was conducted to construct a predictive risk model for postpartum hemorrhage (PPH) in this particular population. METHODS: A prediction model based on the data of 13 hospitals in the UK, Uganda, and Pakistan, from December 2004, to May 2008 was built. A total of 516 patients and 14 potential risk factors were analyzed. The least absolute shrinkage and selection operator regression (LASSO) model was used to optimize feature selection for the PPH risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the LASSO model. Discrimination and calibration were assessed using C-index and calibration plot. RESULTS: Among patients with placenta retention, the incidence of PPH was 62.98% (325/526). Risk factors in the model were country, number of past deliveries, previous manual removal of placenta, place of placenta delivery, and how the placenta was delivered. In these factors, patients in the low-income country (i.e., Uganda) (OR: 1.753, 95% CI=1.055-2.915), retained placentas delivered in the theater (OR: 2.028, 95% CI=1.016-4.050), and having placentas partially removed by controlled cord traction (cct), completely removed manually (OR: 4.722, 95% CI=1.280-17.417) were independent risk factors. The C-statistics was 0.702. CONCLUSIONS: By secondary data analysis, our study constructed a prediction model for PPH in patients with placenta retention, and identified the independent risk factors.

Prospective evaluation of clinical characteristics and maternal outcomes of women with pathologically confirmed postpartum retained placental fragments.

OBJECTIVE: To determine the incidence, risk factors, and short-term maternal outcomes of women with pathologically confirmed retained products of conception (RPOC) following vaginal delivery. METHODS: Prospective cohort study of women with suspicion of RPOC following vaginal delivery, from March 2018 to April 2019. Women were followed for eight weeks postpartum. Women with complete retained placenta were excluded. Women with pathologically confirmed RPOC were compared to those without. Univariate analysis was conducted (ORs; [95% CI]) and was followed by multivariate analysis (aOR; [95% CI]). RESULTS: During the study period, there were 16,583 vaginal deliveries. A total of 96 women (0.58%) with a suspicion of RPOC were enrolled, of these, 53 women (55%) had pathologically confirmed RPOC. The most significant risk factors for pathologically confirmed RPOC were placental abruption (aOR 5.0 [2.29-11.13]) and Oxytocin augmentation of labor (aOR 1.7 [1.07-2.63]). Pathologically confirmed RPOC were associated with higher rates of prolonged hospitalization (OR 9.2 [2.83-30.05]), postpartum hemorrhage (PPH) (OR 6.6 [3.60-11.98]), hemoglobin drop > 3 g/dl (OR 11.4 [5.49-23.49]), and blood transfusion (OR 8.6 [2.07-38.18]). Women who had exploration of uterine cavity without pathological confirmation of RPOC, still had higher rates of perineal laceration (OR 17.6 [4.93-63.08]), PPH (OR 6.1 [3.05-12.21]), and a hemoglobin drop > 3 g/dl (OR 6.0 [2.13-16.95]). CONCLUSIONS: Pathologically confirmed RPOC following vaginal delivery has unique characteristics and is associated with significantly higher rates of PPH and blood transfusions. These findings may assist in the development of better criteria for selecting women for manual exploration and for preventive measures to reduce PPH and complications.

Managing patients with suspected postpartum retained products of conception using a novel sonographic classification.

BACKGROUND: Suspicion of retained products of conception (RPOC) often arises after delivery and still poses a diagnostic and management challenge. PURPOSE: To prospectively evaluate a sonographic classification for the management of patients with suspected RPOC after delivery. MATERIAL AND METHODS: Based on grayscale and Doppler ultrasound parameters, patients were classified into high, moderate, or low probability of RPOC. For the low and moderate probability groups, an ultrasound follow-up at the end of the puerperium was recommended. For the high probability group, a follow-up examination was conducted 10-14 days after the first ultrasound, and patients with persistent high probability findings were referred for surgical intervention. RESULTS: The sample was composed of 215 patients at risk of RPOC. Of these, 100, 93, and 22 patients were classified as having a low, moderate, or high probability of RPOC, respectively. Rates of RPOC were 55%, 2%, and 2% in the high, moderate, and low probability categories, respectively. When the categorization was based on the most recent ultrasound obtained during the puerperium, the adjusted RPOC prevalence rates were 71% in the high, 6% in the moderate, and 0% in the low probability groups. CONCLUSION: This study confirms the effectiveness of our sonographic classification for managing patients with suspected RPOC after delivery. In all three categories, it is recommended to adhere to a conservative management protocol in clinically stable women until the end of the puerperium. This approach provides good predictability for RPOC and can reduce unnecessary surgical interventions.

Manual removal of the placenta and postpartum hemorrhage: A multicenter retrospective study.

AIM: In postpartum women, retained placenta is diagnosed in the absence of signs of placental separation and expulsion, and requires manual removal of the placenta (MROP). MROP may lead to massive hemorrhage, hemodynamic instability, and the need for emergency interventions including blood transfusion, interventional radiology, and hysterectomy. In this study, we aimed to identify the risk factors for retained placenta requiring MROP after vaginal delivery and postpartum hemorrhage (PPH) following MROP. METHODS: A multicenter retrospective study was performed using data from women who delivered at term between 2010 and 2018 at 13 facilities in Japan. Of 36 454 eligible women, 112 women who required MROP were identified. Multivariate logistic regression analyses were conducted to evaluate the risk factors for retained placenta and PPH following MROP. RESULTS: A history of abortion, assisted reproductive technology (ART), instrumental delivery, and delivery of small-for-gestational-age infant were independent risk factors for MROP (adjusted odds ratios [95% confidence intervals]: 1.93 [1.28-2.92], 8.41 [5.43-13.05], 1.80 [1.14-2.82], and 4.32 [1.97-9.48], respectively). ART was identified as an independent risk factor for PPH (adjusted odds ratio [95% confidence interval]: 6.67 [2.42-18.36]) in patients who underwent MROP. CONCLUSION: ART pregnancies significantly increased the risk of retained placenta requiring MROP and PPH. Our results suggest that clinicians need consider patient transfer to a higher-level facility and preparation of sufficient blood products before initiating MROP in cases of ART pregnancies. Our study may assist in identifying high-risk women for PPH before MROP and in guiding treatment decisions, especially in facilities without a blood bank.

Assessing the consequences and economic impact of retained placenta in Holstein dairy cattle.

Retained placenta (RP) is as an important reproductive disorder which adversely affects the economic performance of dairy cows. Understanding the consequences and economic losses associated with RP can persuade dairy farmers to consider it more effectively in their management decisions. Hence, the aims of this research were to assess the effect of RP on production and reproduction attributes as well as economic losses in Iranian Holstein cows. The data was collected from nine Holstein dairy herds in Isfahan province of Iran. The final dataset comprised of 139,508 records of 58,086 cows which calved between March 2011 and December 2018. A linear mixed model was developed to evaluate the effect of RP on individual performance of primiparous and multiparous cows. The economic losses associated with the RP were finally estimated. The average incidence of RP per cow over a year was 12.3% (ranged between 9.0 and 15.4%). Each incidence of RP significantly reduced milk, fat and protein yields in primiparous and multiparous cows (P < 0.05). The adverse effect of RP on the milk production was much higher in the cows at the early phase of lactation (i.e. 100-d lactation group) than the cows in mid or late lactation. The estimated production losses (±standard deviation) due to the RP event were 282.1 ± 43.0 and 295.7 ± 40.8 kg per cow for a 305-d lactation period in primiparous and multiparous cows, respectively. However, the fertility performance was less affected by the RP in primiparous compared to multiparous cows. The average of days open increased by 8.3 ± 5.3 and 19.8 ± 7.1 d in primiparous and multiparous cows, respectively. The financial losses associated with RP were on average US$ 350.4 and US$ 481.2 per incidence in primiparous and multiparous cows, respectively, ranged from US$ 311.9 to 456.2 depending on the parity number (primi- or multiparous) and herd management. The highest financial losses due to RP were associated with reduction in milk production (38.5% of total loss) and low fertility (28.5% of total loss) had the highest contribution in in primiparous and multiparous cows, respectively. The results of our research highlight the economic importance of improved calving management to reduce RP occurrence in dairy cows.

Risk factors for non-adherent retained placenta after vaginal delivery: a systematic review.

BACKGROUND: Retained placenta represents a cause of maternal morbidity and mortality affecting 0.5-3% of all vaginal deliveries. The unpredictability of this condition makes difficult to develop predictive and preventive strategies to apply in clinical practice. This analysis collected and analyzed all known risk factors related to this obstetric complication. METHODS: A systematic literature review for all original research articles published between 1990 and 2020 was performed. Observational studies about retained placenta risk factors published in English language were considered eligible. Conference abstracts, untraceable articles and studies focused on morbidly adherent placenta were excluded. The included articles were screened to identify study design, number of enrolled patients and retained placenta risk factors investigated. All stages of the revision followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. RESULTS: Thirty-five studies met the inclusion criteria. The reported retained placenta prevalence ranged from 0.5 to 4.8%. Maternal age, previous cesarean sections, previous dilation and curettage, previous retained placenta, labor induction, resulted as the most recurrent, independent risk factors for retained placenta. Previous estro-progestins therapy, morphological placental features (weight, shape, insertion of umbilical cord, implantation site), endometriosis, Assisted Reproductive Technologies, Apgar score are fascinating new proposal risk factors. CONCLUSIONS: Old and new data are not enough robust to draw firm conclusions. Prospective and well-designed studies, based on a well agreed internationally retained placenta definition, are needed in order to clarify this potential dramatic and life-threatening condition.

Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study.

PURPOSE: The association between placental detachment disorders and risk of chronic disease is unclear. We determined the association of placenta accreta and retained placenta with risk of future maternal cardiovascular disease and cancer. METHODS: We tracked a longitudinal cohort of 541,051 pregnant women over a period of 13 years (2006-2019) in Quebec, Canada. The main exposure measures were placenta accreta and retained placenta in any pregnancy. Outcomes included future hospitalizations for cardiovascular disease and cancer. Using Cox regression models adjusted for maternal characteristics, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of accreta and retained placenta with cardiovascular disease and cancer at 13 years. RESULTS: The incidence of cardiovascular hospitalization was 21.2 per 10,000 person-years for accreta and 23.4 per 10,000 for retained placenta with postpartum hemorrhage, compared with 20.3 per 10,000 for neither placental disorder. Cancer incidence followed a similar pattern, with rates highest for retained placenta with hemorrhage. Retained placenta with hemorrhage was associated with 1.19 times the risk of cardiovascular disease (95% CI 1.03-1.38) and 1.27 times the risk of cancer (95% CI 1.06-1.53). Retained placenta with hemorrhage was associated with heart failure (HR 1.84, 95% CI 1.04-3.27), cardiomyopathy (HR 1.88, 95% CI 1.03-3.43), and cervical cancer (HR 2.03, 95% CI 1.17-3.52). Accreta and retained placenta without hemorrhage were not associated with these outcomes. CONCLUSION: Retained placenta with hemorrhage may be a risk marker for cardiovascular disease and certain cancers later in life.

Retained placenta and postpartum hemorrhage: time is not everything.

PURPOSE: Postpartum hemorrhage is the major cause of maternal mortality worldwide. Retained placenta accounts for nearly 20% of severe cases. We investigated the influence of the time factor and retained placenta etiology on postpartum hemorrhage dynamics. METHODS: Our retrospective study analyzed a single-center cohort of 296 women with retained placenta. Blood loss was measured using a validated and accurate technique based on calibrated blood collection bags, backed by the post- vs pre-partum decrease in hemoglobin. We evaluated the relationship between these two blood loss parameters and the duration of the third stage of labor using Spearman rank correlation, followed by subgroup analysis stratified by third stage duration and retained placenta etiology. RESULTS: Correlation analysis revealed no association between third stage duration and measured blood loss or decrease in hemoglobin. A shorter third stage (< 60 min) was associated with significantly increased uterine atony (p = 0.001) and need for blood transfusion (p = 0.006). Uterine atony was significantly associated with greater decrease in hemoglobin (p < 0.001), higher measured blood loss (p < 0.001), postpartum hemorrhage (p = 0.048), and need for blood transfusion (p < 0.001). CONCLUSION: Postpartum blood loss does not correlate with third stage duration in women with retained placenta. Our results suggest that there is neither a safe time window preceding postpartum hemorrhage, nor justification for an early cut-off for manual removal of the placenta. The prompt detection of uterine atony and immediate prerequisites for manual removal of the placenta are key factors in the management of postpartum hemorrhage.

Predicting the risk of retained fetal membranes and metritis in dairy cows according to prepartum hemogram and immune and metabolic status.

Uterine diseases affect a significant proportion of dairy cows, causing significant economic losses. Immune and metabolic statuses are associated with the risk of retained fetal membranes (RFM) and metritis. The hypothesis of this study was that it is possible to use such responses to predict the risk of RFM and metritis. Data from cows (Jersey = 143, Holstein = 116) previously used in four experiments were used. Cow factors [parity, BCS change from -28 to 0 d relative to calving, calf sex, calving problems (twins, stillbirth, dystocia)] were evaluated for their association with the risk of RFM and metritis. Blood samples collected in the last week of gestation were used to measure polymorphonuclear leukocyte phagocytosis, oxidative burst, and expression of CD18 and CD62L, total blood count, haptoglobin optical density, and concentrations of glucose, non-esterified fatty acids, and ß-hydroxybutyrate. Cows were treated with egg ovalbumin at -21, -7, and 7 d relative to calving and blood samples were used to determine the anti-ovalbumin IgG optical density. Univariable analyses were carried out to identify variables associated with the risk of RFM and metritis. The significant (P ≤ 0.15) variables were included in multivariable models from which variables with P > 0.15 were removed in a backward stepwise fashion. Risk of RFM was reduced in the absence of calving problems [adjusted odds ratio (AOR) 95 % confidence interval (CI) = 0.13 (0.02, 0.86)], when intensity of phagocytosis [AOR (95 % CI) = 0.50 (0.25, 1.04)] and expression of CD62L [AOR (95 % CI) = 0.71 (0.46, 1.09)] by polymorphonuclear leukocyte were greater, and when prepartum non-esterified fatty acid concentration was lower [AOR (95 % CI) = 8.71 (0.49, 153.84)]. Calf sex [AOR (95 % CI) = 0.35 (0.10, 1.25)], calving problem [AOR (95 % CI) = 0.14 (0.02, 1.08)], PMNL phagocytosis intensity [AOR (95 % CI) = 0.72 (0.47, 1.11)], polymorphonuclear leukocyte intensity of expression CD18 [AOR (95 % CI) = 0.78 (0.60, 1.00)] and CD62L [AOR (95 % CI) = 0.77 (0.60, 0.98)], and haptoglobin optical density [AOR (95 % CI) = 1.16 (0.97, 1.39)] were associated with metritis. Indexes generated from the estimates of the multivariable analyses to predict the risk of RFM [area under the curve = 0.77 (95 % CI = 0.70 to 0.84)] and metritis [area under the curve = 0.76 (95 % CI = 0.70, 0.81)] demonstrated that polymorphonuclear leukocyte function, non-esterified fatty acid concentration, and haptoglobin optical density prepartum may be used as predictors of uterine diseases.