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.

The magnitude and associated factors of postpartum hemorrhage among mothers who delivered at Debre Tabor general hospital 2018.

OBJECTIVE: Since data related to postpartum hemorrhage in Ethiopia is scarce, this study was aimed to assess the magnitude and associated factors of postpartum hemorrhage among mothers who delivered in Debre Tabor general hospital. RESULTS: In this study, one hundred forty-four mothers' charts were reviewed which made the response rate 100%. This study revealed that the magnitude of postpartum hemorrhage was 7.6% (CI 6.2, 9.8). Chi-square test revealed that there was an association between postpartum hemorrhage and gravidity, parity, having antenatal care visit, and the previous history postpartum hemorrhage. This finding confirmed that uterine atony, retained placenta, and genital tract trauma were the most common leading cause of postpartum hemorrhage.

The increasing role of a retained placenta in postpartum blood loss: a cohort study.

PURPOSE: To describe the association between quantity of blood loss, duration of the third stage of labour, retained placenta and other risk factors, and to describe the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage. METHODS: Cohort study of all vaginal deliveries at two Danish maternity units between 1 January 2009 and 31 December 2013 (n = 43,357), univariate and multivariate linear regression statistical analyses. RESULTS: A retained placenta was shown to be a strong predictor of quantity of blood loss and duration of the third stage of labour a weak predictor of quantity of blood loss. The predictive power of the third stage of labour was further reduced in the multivariate analysis when including retained placenta in the model. There was an increase in the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage, increasing from 12% in cases of blood loss ≥ 500 ml to 53% in cases of blood loss ≥ 2000 ml CONCLUSION: The predictive power of duration of the third stage of labour in regard to postpartum blood loss was diminished by the influence of a retained placenta. A retained placenta was, furthermore, present in the majority of most severe cases.

Aetiology and treatment of severe postpartum haemorrhage.

This thesis is comprised of three studies focusing on severe postpartum haemorrhage (PPH). PPH is a major cause of maternal morbidity and mortality worldwide. Risk factors include retained placenta, prolonged duration of the third stage of labour, previous caesarean section, and operative vaginal delivery. Occurrence and development of PPH are, however, unpredictable and can sometimes give rise to massive haemorrhage or even hysterectomy and maternal death. Severe haemorrhage can lead to coagulopathy causing further haemorrhage and requiring substitution with blood transfusions. The aim of this thesis was to investigate causes of severe PPH and investigate methods of early prevention. 
The first study was a randomised controlled double-blinded trial investigating the effect of treatment with pre-emptive fibrinogen on women with severe PPH. The primary outcome was the need for red blood cell transfusion at 6 weeks postpartum. A total of 249 women were randomised to either 2 grams of fibrinogen or placebo. The mean concentration of fibrinogen increased significantly in the intervention group compared to the placebo group (0.40 g/l, confidence interval: 0.15-0.65), but there was no difference in the need for postpartum blood transfusions (relative risk 0.95, confidence interval: 0.15-1.54). No thromboembolic complications were detected.
The second study was a population-based observational study including 245 women receiving ≥10 red blood cell transfusion due to PPH. The cohort was identified by combining data from The Danish Transfusion Database with The Danish Medical Birth Registry, with further data extraction and validation through review of patient charts. The main causes of massive postpartum transfusion were atony (38%) and abnormal invasive placenta (25%). Two of the women in the cohort died, an additional six had a cardiac arrest, and a total of 128 women (52%) required a hysterectomy. Hysterectomy was associated with increased blood loss, increased number of blood transfusions, a higher fresh frozen plasma to red blood cell ratio (p=0.010), and an increased number of red blood cells before first platelet transfusion (p=0.023). Hysterectomy led to haemostasis in only 70% of cases.
The third study was a register-based cohort study, includ-ing 43,357 vaginal deliveries from two large Danish maternity units. Different cut-offs were used to define PPH. There was a difference in distribution of causes depending on the cut-off used, with atony playing a decreasing role and a retained placenta an increasing role the higher the cut-off used. In a multivariate linear regression model retained placenta was identified as a strong predictor of quantity of blood loss. The duration of the third stage of labour was a very weak predictor after adjusting for the influence of a retained placenta. 
In conclusion, an improved diagnosis of the causes of PPH especially retained placenta, together with an early recognition and treatment of coagulopathy, seem to be important in reducing severe PPH in an aim to minimize associated maternal morbidity.

Underlying mechanisms of retained placenta: Evidence from a population based cohort study.

OBJECTIVE: To determine risk factors for retained placenta, and to identify supporting epidemiologic evidence for the three previously-proposed mechanisms: (i) invasive placentation, (ii) placental hypo-perfusion, and (iii) inadequate uterine contractility. DESIGN: A retrospective population-based cohort study. SETTING AND POPULATION: Israeli population in the southern district. METHODS: Data were analyzed from a tertiary hospital database, between 1989 and 2014, using univariate tests and generalized estimating equation (GEE) multivariable models. MAIN OUTCOME MEASURES: Prevalence of retained placenta. RESULTS: The study population included 205,522 vaginal deliveries of which 4.8% (n=9870) were complicated with retained placenta. Previous intra-uterine procedures and placenta-related pregnancy complications were found to be significant risk factors for retained placenta (history of cesarean section aOR=8.82, 95%CI 8.35-9.31; history of curettage aOR=12.80, 95%CI 10.57-15.50; pre-eclampsia aOR=1.25, 95%CI 1.14-1.38; delivery of a small for gestational age neonate aOR=1.08, 95%CI 1.01-1.16; stillbirth aOR=2.34, 95%CI 1.98-2.77). During labour, the risk for retained placenta was increased in presence of arrest of dilatation (aOR=2.03, 95%CI 1.08-3.82) or arrest of descent (aOR=1.55, 95%CI 1.22-1.96). Infections of the uterine cavity during labour were also found to be strongly associated with increased risk of retained placenta (endometritis aOR=2.21, 95%CI 1.64-2.97; chorioamnionitis aOR=3.35, 95% CI 2.78-4.04). CONCLUSIONS: Supporting epidemiologic evidence were found for all three underlying mechanisms. In addition, there is evidence to suggest that intrauterine infection and inflammation may also be a possible pathology associated with retained placenta. TWEETABLE ABSTRACT: Risk factors for retained placenta support previously proposed mechanisms in a large cohort study.

Peripartum hysterectomy incidence, risk factors and clinical characteristics in Ireland.

BACKGROUND: The incidence of peripartum hysterectomy (PH) shows fifty-fold variation worldwide (0.2-10.5/1000 deliveries) and risk factors include advancing maternal age and parity, previous caesarean section (CS) and abnormal placentation. OBJECTIVES: In this first national study of PH in Ireland, our objectives were threefold: to describe the national trend in PH incidence over 15 years since 1999; to assess risk of PH associated with morbidly adherent placenta (MAP), placenta praevia and postpartum haemorrhage (PPH) during 2005-2013; and to describe the causes, interventions and outcomes of PH cases during 2011-2013. STUDY DESIGN: For the 15-year time-trend analysis, PH cases and denominator data were extracted from Ireland's Hospital In-Patient Enquiry database. Multivariate Poisson regression analysis assessed risk of PH associated with MAP, placenta praevia and PPH. In collaboration with the 20 Irish maternity units we carried out a three-year national clinical audit of severe maternity morbidity. PH was a notifiable morbidity and the audit included detailed review of MOH cases. RESULTS: In 1999-2013 there were 298 PH cases, a rate of 0.32/1000 deliveries. During the period 2005-2013, the PH rate was 50 times higher in deliveries involving PPH, 100 times higher with placenta praevia and 1000 times higher with MAP. During the clinical audit (2011-2013) there were 65 PH cases, a rate of 0.33/1000 deliveries, increasing with advancing age and parity. The reporting of abnormal placentation, primarily the co-occurrence of placenta praevia and MAP, was linked with previous CS. Fifty-six of the 65 cases suffered MOH, most commonly associated with placenta praevia, MAP and uterine atony. Prophylactic and therapeutic uterotonic agents were appropriately used in the majority of cases. CONCLUSIONS: The incidence of PH in Ireland has been consistently low over 15 years, averaging one case every 3000 deliveries. The recognised risk factors of MAP, placenta praevia and PPH were independently associated with PH, with MAP being by far the strongest predictor. The vast majority of PH cases in our clinical audit were associated with MOH. Some deficiencies were noted in antenatal care, in certain elements of treatment and clinical governance protocols but adherence to guidelines was generally high.

Retained placenta: will medical treatment ever be possible?

The standard treatment for retained placenta is manual removal whatever its subtype (adherens, trapped or partial accreta). Although medical treatment should reduce the risk of anesthetic and surgical complications, they have not been found to be effective. This may be due to the contrasting uterotonic needs of the different underlying pathologies. In placenta adherens, oxytocics have been used to contract the retro-placental myometrium. However, if injected locally through the umbilical vein, they bypass the myometrium and perfuse directly into the venous system. Intravenous injection is an alternative but exacerbates a trapped placenta. Conversely, for trapped placentas, a relaxant could help by resolving cervical constriction, but would worsen the situation for placenta adherens. This confusion over medical treatment will continue unless we can find a way to diagnose the underlying pathology. This will allow us to stop treating the retained placenta as a single entity and to deliver targeted treatments.

Does the presence of placental basal plate myometrial fibres increase the risk of subsequent morbidly adherent placenta: a case-control study.

OBJECTIVE: Antenatal diagnosis of morbidly adherent placenta has been shown to improve outcomes, but existing predictors lack sensitivity. Our objective was to determine whether the presence of myometrial fibres attached to the placental basal plate (BPMYO) in an antecedent pregnancy is associated with subsequent morbidly adherent placenta. DESIGN: A case-control study. SETTING: Departments of Obstetrics and Gynecology and Pathology, Northwestern University, Chicago, IL, USA. SAMPLE: Women who had at least two pregnancies with placental pathological evaluation. METHODS: Cases were defined as women with evidence of morbidly adherent placenta (both clinically and pathologically) in their most recent pregnancy whereas women without evidence of morbidly adherent placenta served as controls. Pathological specimens of placentas from previous pregnancies were evaluated for BPMYO. The presence of BPMYO on a previous placenta was evaluated to determine whether it could be used to improve the antenatal diagnosis of morbidly adherent placenta. RESULTS: Of the 25 cases of morbidly adherent placenta, 19 (76%) had BPMYO present on their previous placenta compared with 41 (41%) of controls (odds ratio 4.8, 95% CI 1.8-13.0). Adding BPMYO to a regression including other risk factors for morbidly adherent placenta (i.e. maternal age, number of previous caesarean sections, placenta praevia, previous multiple gestation, any previous curettage, and ultrasonographic suspicion of placenta accreta) significantly improved the sensitivity of antenatal diagnosis of morbidly adherent placenta (61% versus 39%, P < 0.001) without a change in specificity (97% versus 97%, P = 1.00). CONCLUSION: BPMYO on previous placental pathology is associated with an increased risk of morbidly adherent placenta in a subsequent pregnancy. These findings may shed light on the pathophysiology of accreta and inform future research on predictors of accreta. TWEETABLE ABSTRACT: Previous basal plate myometrium improves the ability to detect subsequent morbidly adherent placenta.

AN APPRAISAL OF RETAINED PLACENTA AT THE UNIVERSITY OF PORT HARCOURT TEACHING HOSPITAL: A FIVE-YEAR REVIEW.

BACKGROUND: Retained placenta is associated with an increased risk of maternal morbidity and mortality especially in developing countries. OBJECTIVE: To determine the incidence and evaluate the mode of presentation, risk factors and method of treatment of patients with retained placenta. METHODOLOGY: A retrospective review of retained placenta managed at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt over a 5 year period (January 2009 to December 2013). Data obtained were analyzed using statistical software SPSS 17.0. RESULTS: There were 93 cases of retained placenta out of 15,789 deliveries, giving an incidence of 0.59%.85 patients' case records were available for analysis. Majority of the patients 69 (81.2%) were unbooked (had no antenatal care) with 60 (70.6%) having home deliveries. Previous history of dilatation and curettage and preterm deliveries, accounted for the major identifiable risk factors at 55 (64.7%) and 22 (25.9%) respectively. At presentation, 22(25.9%) were in hypovolemic shock. Manual removal of the placenta was the commonest treatment modality (87.1%).There was one maternal death giving rise to a case fatality rate of 1.18%. CONCLUSION: Retained placenta is a major cause of maternal morbidity and mortality from postpartum haemorrhage and other complications related to its removal. The incidence can be reduced by antenatal care, skilled birth attendance and provision of emergency obstetrics care services.

[Death of two mares with retained fetal membranes]. / Tod zweier Stuten mit Retentio secundinarum.

Retained fetal membranes in mares is a relative frequent disease which can lead to severe complications. Two case studies are described in which mares died acutely despite intensive care. Pathological examination confirmed severe hemorrhage as the cause of death in both animals.

Carbetocin versus intra-umbilical oxytocin in the management of retained placenta: a randomized clinical study.

AIM: This study aimed to compare the hemodynamic profile and efficacy of carbetocin versus intra-umbilical oxytocin in the management of retained placenta following vaginal delivery. MATERIAL AND METHODS: In this randomized clinical study, women with retained placenta for more than 30 min were assigned to receive either an i.v. bolus of 100-µg carbetocin (n = 38) or an intra-umbilical vein injection of 50 IU oxytocin in 30 mL saline (n = 40). The main parameters evaluated were the success rate for expulsion of the placenta and the effects of these drugs on maternal blood pressure. RESULTS: The success rate in the carbetocin group was 86.84% compared to 77.5% in the intra-umbilical oxytocin group. Notably, 57.7% of the participants had prior induction of labor or augmentation during labor. There were no significant differences between the two groups regarding the estimated blood loss, drop of hemoglobin within the first 48 h, additional uterotonic injection or the need for manual removal of the placenta. Systolic blood pressure was significantly lower in the intra-umbilical oxytocin group at 30 and 60 min after injection (P = 0.008, 0.026, respectively). Nonetheless, diastolic blood pressure was significantly lower in the intra-umbilical oxytocin group than in the carbetocin group at 30 min (P = 0.036). CONCLUSION: A single i.v. bolus of carbetocin and umbilical vein injection of 50 IU oxytocin are similarly effective in reducing the need for manual removal of the placenta. Carbetocin seems to have an acceptable hemodynamic safety profile and can be used as an alternative choice to the conventional oxytocic agents in the management of retained placenta.

Herd-level association of serum metabolites in the transition period with disease, milk production, and early lactation reproductive performance.

The objective was to identify herd-level indicators expressed as a proportion of sampled animals with increased nonesterified fatty acids (NEFA) or ß-hydroxybutyric acid (BHBA), or decreased calcium in wk -1 and wk +1 relative to calving that were associated with herd-level incidence of retained placenta, metritis and displaced abomasum, milk production, and probability of pregnancy at the first artificial insemination (AI). Fifty-five Holstein freestall dairy herds in the United States and Canada were visited weekly. Blood was collected from 2,365 cows around parturition, and serum concentrations of NEFA, BHBA, and calcium were determined. Different cow-level metabolite thresholds associated with detrimental health or productivity in previous studies were used to classify animals into high- and low-risk metabolite concentration groups. For wk -1 and wk +1 relative to calving, a herd-level threshold was determined as the proportion of sampled animals in the high-risk metabolite concentration groups with the strongest association with increased incidence of disease, milk loss, or decreased pregnancy at the first AI. The odds of displaced abomasum after calving were higher in herds that had ≥ 25% of the animals with BHBA ≥ 1,400 µmol/L in wk +1 [odds ratio (OR)=2.1; 95% confidence interval (CI)=1.0-4.2)] or ≥ 35% of the animals with calcium ≤ 2.1 mmol/L in wk +1 (OR=2.4; CI=1.3-4.3). Herd-level thresholds of ≥15% of the cows with BHBA ≥ 800 µmol/L in wk -1 and ≥ 15% of the cows with calcium ≤2.1mmol/L in wk +1 were associated with milk loss (±SE) of 4.4±1.7 and 3.8 ± 1.4 kg/d per cow, respectively. When only multiparous cows were considered, herds with ≥30% of the multiparous cows with NEFA ≥0.5 mEq/L in wk -1 were associated with a 3.0 ± 1.5 kg/d per cow milk loss. The odds of pregnancy at first AI were lower in herds that had ≥ 5% of the cows with calcium ≤ 2.1 mmol/L in wk -1 (OR=0.7; CI=0.5-1.0), or ≥ 30% of the cows with NEFA ≥ 1.0 mEq/L (OR=0.6; CI=0.4-0.9) or ≥ 25% of the cows with calcium ≤2.1 mmol/L in wk +1 (OR=0.7; CI=0.5-0.9). When only multiparous cows were considered, the odds of pregnancy at first AI were lower in herds that had ≥50% of multiparous cows with NEFA ≥0.5 mEq/L in wk -1 (OR=0.5; CI=0.2-0.9). In conclusion, several herd-level thresholds for the proportion of cows with increased NEFA or BHBA, or decreased calcium in the week before and after calving were associated with higher risk of displaced abomasum, milk loss at the first Dairy Herd Improvement Association test, and decreased pregnancy at first AI. The association found between precalving BHBA and milk production is promising due to the availability of several cow-side tests for measuring BHBA. Some of the herd-level associations differed from the previously described cow-level associations, suggesting the potential of interpreting periparturient metabolic challenges at the herd level, where changes in diet and management are generally implemented.

On-farm evaluation of the effect of metabolic diseases on the shape of the lactation curve in dairy cows through the MilkBot lactation model.

The effects of metabolic diseases (MD) occurring during the transition period on milk production of dairy cows have been evaluated in many different ways, often with conflicting conclusions. The present study used a fitted lactation model to analyze specific aspects of lactation curve shape and magnitude in cows that avoided culling or death in the first 120 d in milk (DIM). Production and health records of 1,946 lactations in a 1-yr follow-up study design were collected from a transition management facility in Germany to evaluate both short- and long-term effects of MD on milk production. Milk production data were fitted with the nonlinear MilkBot lactation model, and health records were used to classify cows as healthy (H), affected by one MD (MD), or by multiple MD (MD+). The final data set contained 1,071 H, 348 MD, and 136 MD+ cows, with distinct incidences of 3.7% twinning, 4.8% milk fever, 3.6% retained placenta, 15.4% metritis, 8.3% ketosis, 2.0% displaced abomasum, and 3.7% mastitis in the first 30 DIM. The model containing all healthy and diseased cows showed that lactations classified as H had milk production that increased faster (lower ramp) and also declined faster (lower persistence) compared with cows that encountered one or more metabolic problems. The level of production (scale) was only lowered in MD+ cows compared with H and MD cows. Although the shape of the lactation curve changed when cows encounter uncomplicated (single) MD or complicated MD (more than one MD), the slower increase to a lower peak seemed to be compensated for by greater persistency, resulting in the overall 305-d milk production only being lowered in MD+ cows. In the individual disease models, specific changes in the shape of the lactation curve were found for all MD except twinning. Milk fever, retained placenta, ketosis, and mastitis mainly affected the lactation curve when accompanied by another MD, whereas metritis and displaced abomasum affected the lactation curve equally with or without another MD. Overall, 305-d milk production was decreased in complicated metritis (10,603 ± 50 kg vs. 10,114 ± 172 kg). Although care should be taken in generalizing conclusions from a highly specialized transition management facility, the current study demonstrated that lactation curve analysis may contribute substantially to the evaluation of both short- and long-term effects of metabolic diseases on milk production by detecting changes in the distribution of production that are not apparent when only totals are analyzed.

Effect of reproductive disorders and parity on repeat breeder status and culling of dairy cows in Quebec.

This study quantified the effect of peripartum reproductive disorders and parity on repeat breeder status and involuntary culling of dairy cows. Reproductive data of 418 383 lactations were taken from a computerized databank of health records for dairy cows. A logistic regression model was used with dystocia, retained placenta (RP), metritis complex, and parity as fixed effect risk factors and herd entered as the random effect. Of the peripartum problems studied, dystocia had the greatest effect on future fertility. Dystocia increased the odds of a cow being a repeat breeder by 44% [odds ratio (OR): 1.44; confidence interval (CI): 1.37 to 1.51]. Compared to first-parity cows, cows in second, third, and fourth parities had significantly higher odds of being a repeat breeder: 18% (OR: 1.18; CI: 1.16 to 1.20); 24% (OR: 1.24; CI: 1.21 to 1.26); and 42% (OR: 1.42; CI: 1.39 to 1.45), respectively. The odds for second-, third-, or fourth-parity repeat breeders being culled were 24% (OR: 1.24; CI: 1.20 to 1.28); 39% (OR: 1.39; CI: 1.35 to 1.43); and 67% (OR: 1.67; CI: 1.62 to 1.71) respectively, while peripartum reproductive problems had less of an effect.

Intraumbilical injection of three different uterotonics in the management of retained placenta.

AIM: The aim of this work was to compare the effect of intraumbilical injection of three different uterotonic solutions in the management of retained placenta. MATERIALS AND METHODS: This study was conducted in Ain-Shams University Maternity Hospital, Cairo, Egypt. A total of 78 women with retained placenta (>30 min after delivery of the fetus) were included in the study and subdivided into three groups. Each group was injected with a different type of uterotonic into the umbilical vein after clamping it using the Pipingas technique. Uterotonics used were either 20 IU oxytocin dissolved in 30 mL saline (n=26), ergometrine 0.2 mg dissolved in 30 mL saline (n=27) or misoprostol 800 µg dissolved in 30 mL saline (n=25). RESULTS: The overall success rate of spontaneous placental separation within 30 min after intraumbilical injection of uterotonics was 56/78 (71.79%). The success rate was higher with misoprostol when compared to oxytocin and ergometrine but the difference was not significant (20/25 [80%], 19/26 [73.08%], 17/27 [62.96%], respectively, P>0.05). The injection-to-separation interval was significantly shorter in the misoprostol group than in the oxytocin and ergometrine groups (7.0±2.2 min, 13.14±3.76 min, 22.5±4.37 min, respectively, P<0.001). CONCLUSION: Intraumbilical injection of uterotonics, namely oxytocin, ergometrine and dissolved misoprostol in saline, are closely effective in the management of retained placenta, with misoprostol being slightly more effective. This method may have a role in minimizing the need for manual removal of the placenta and its adverse sequelae.

Effects of postpartum uterine diseases on milk production and culling in dairy cows.

The objective was to quantify the effect of postpartum uterine diseases on milk production and culling. Data from 2,178 Holstein cows in 6 herds enrolled in a randomized clinical trial were used. Milk production data from the first 4 Dairy Herd Improvement Association (DHIA) test-days and culling data from farm records were collected. Retained placenta (RP; ≥24 h after parturition) and metritis [≤20 d in milk (DIM)] were diagnosed by farm managers using standardized definitions. Farms were visited weekly and cows were examined at 35 and 56 (±3) DIM using endometrial cytology (cytobrush device), vaginal discharge scoring (Metricheck device), and measurement of cervical diameter by transrectal palpation. Diagnostic criteria for cytological endometritis (CYTO) and purulent vaginal discharge (PVD) were established based on a detrimental effect on subsequent reproduction. Statistical analyses were performed using linear mixed models, logistic regression models, and Cox proportional hazard models, accounting for the effects of experimental treatments and herd clustering. Milk production and culling were the outcomes. Primiparous and multiparous cows were modeled separately for milk production. Milk production of primiparous cows was unaffected by uterine diseases. The effect of metritis on milk production was variable over time in multiparous cows: it decreased production per cow by 3.7 kg at the first DHIA test, but was not different at later tests. Retained placenta decreased milk production by 2.6 kg/d in multiparous cows through the first 4 DHIA tests. The projected effects of metritis and RP in multiparous cows were reductions of 259 kg and 753 kg over 305 DIM, respectively; these effects were additive. Neither CYTO nor PVD affected milk production. Culling risks at 30 and 63 DIM were unaffected by RP and metritis. Culling hazard up to 300 DIM was unaffected by RP, metritis, CYTO, or PVD, whether or not pregnancy status, milk production, and displaced abomasum were accounted for. Uterine disease decreased pregnancy rate, which was a substantial risk factor for culling; however, if affected cows became pregnant they were not at greater risk of culling.