Uterine Sacculation With Entrapped Placenta After Delivery.

BACKGROUND: Uterine sacculation refers to a temporary pouch or sac within the uterus that may contain the placenta or fetal parts and that may be diagnosed antepartum or after delivery. There is very limited published information about this rare condition and its management. CASES: We report two cases of uterine sacculation with entrapped placenta diagnosed immediately postpartum, managed with two different approaches. In one case, the patient underwent immediate laparotomy and placental extraction. In the second case, the patient was managed conservatively but ultimately developed signs of infection and underwent laparotomy. CONCLUSION: Uterine sacculation with entrapped placenta is a rare condition that is a potential etiology of retained placenta. Obstetric clinicians should be aware of this diagnosis and the management strategies available.

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.

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.

A novel method for office aspiration curettage in cases of retained products of conception: A randomized controlled trial.

INTRODUCTION: Missed abortion can be treated with medication or aspiration curettage. A Karman aspiration cannula is another option. We evaluated its success in evacuating retained products of conception (RPOC) based on symptoms, endometrial thickness, endometrial irregularity, and blood flow seen on Doppler ultrasound (indicative of placenta). MATERIAL AND METHODS: This prospective, randomized, nonblinded trial was conducted in a university-affiliated medical center. It included 40 women diagnosed with missed abortion and two failed courses of 600 µg buccal misoprostol, one  week apart, randomly assigned to treatment or controls. One week after the second misoprostol course, immediately after evaluating endometrial thickness, endometrial irregularity using Doppler ultrasound, and with blood flow indicative of RPOC, women in the aspiration group underwent endometrial suction with a Karman aspiration cannula. The 5-6 mm cannula attached to a 60 mL syringe was inserted into the uterus under ultrasound guidance. The contents were aspirated until the uterus was empty. Control group patients did not receive additional treatment. All were scheduled for ambulatory, operative hysteroscopy under anesthesia 1 month later (departmental protocol). On that day, all women with RPOC on Doppler ultrasound underwent hysteroscopy. Bleeding days, days with pain, pain according to visual analog scale, length of hospitalization, and infection rate were recorded. NIH clinical trial registration number NCT02917785. RESULTS: In the study group, 90% did not need hysteroscopy, compared with 50% of controls (p = 0.014). No complications were noted. At all visits, we used Doppler ultrasound to exclude or confirm RPOC. Pathology revealed RPOC in all women who underwent aspiration. Average visual analog scale score for office aspiration (n = 20) was 4.9 ± 3.6. vs. 6.3 ± 3.4 for the first (p = 0.157) and 4.7 ± 3.3 for the second (p = 0.836) misoprostol treatment cycle. The treatment group experienced 6.1 days of bleeding and the control group experienced 1.4 days (p = .006). CONCLUSIONS: Based on our criteria of diagnosing RPOC according to symptoms, endometrial thickness, endometrial irregularity, and blood flow indicative of placental tissue seen on Doppler ultrasound and histo-pathological confirmation, aspiration using Karman cannula can be an effective therapeutic approach. It may be a safe alternative for women with RPOC after misoprostol failure.

Managing Reproduction Emergencies in the Field: Part 2: Parturient and Periparturient Conditions.

Selected conditions affecting broodmares are discussed, including arterial rupture, dystocia, foal support with ex utero intrapartum treatment, uterine prolapse, postpartum colic, the metritis/sepsis/systemic inflammatory response syndrome complex, and retained fetal membranes. Postpartum colic beyond third-stage labor contractions should prompt comprehensive evaluation for direct injuries to the reproductive tract or indirect injury of the intestinal tract. Mares with perforation or rupture of the uterus are typically recognized 1 to 3 days after foaling, with depression, fever, and leukopenia; laminitis and progression to founder can be fulminant. The same concerns are relevant in mares with retention of fetal membranes.

Umbilical vein injection for management of retained placenta.

BACKGROUND: Retained placenta is a common complication of pregnancy affecting 1% to 6% of all births. If a retained placenta is left untreated, spontaneous delivery of the placenta may occur, but there is a high risk of bleeding and infection. Manual removal of the placenta (MROP) in an operating theatre under anaesthetic is the usual treatment, but is invasive and may have complications. An effective non-surgical alternative for retained placenta would potentially reduce the physical and psychological trauma of the procedure, and costs. It could also be lifesaving by providing a therapy for settings without easy access to modern operating theatres or anaesthetics. Injection of uterotonics into the uterus via the umbilical vein and placenta is an attractive low-cost option for this. This is an update of a review last published in 2011. OBJECTIVES: To assess the use of umbilical vein injection (UVI) of saline solution with or without uterotonics compared to either expectant management or with an alternative solution or other uterotonic agent for retained placenta. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 June 2020), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing UVI of saline or other fluids (with or without uterotonics), either with expectant management or with an alternative solution or other uterotonic agent, in the management of retained placenta. We considered quasi-randomised, cluster-randomised, and trials reported only in abstract form. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. We calculated pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs), and presented results using 'Summary of findings' tables. MAIN RESULTS: We included 24 trials (n = 2348). All included trials were RCTs, one was quasi-randomised, and none were cluster-randomised. Risk of bias was variable across the included studies. We assessed certainty of evidence for four comparisons: saline versus expectant management, oxytocin versus expectant management, oxytocin versus saline, and oxytocin versus plasma expander. Evidence was moderate to very-low certainty and downgraded for risk of bias of included studies, imprecision, and inconsistency of effect estimates. Saline solution versus expectant management There is probably little or no difference in the incidence of MROP between saline and expectant management (RR 0.93, 95% CI 0.80 to 1.10; 5 studies, n = 445; moderate-certainty evidence). Evidence for the following remaining primary outcomes was very-low certainty: severe postpartum haemorrhage 1000 mL or greater, blood transfusion, and infection. There were no events reported for maternal mortality or postpartum anaemia (24 to 48 hours postnatal). No studies reported addition of therapeutic uterotonics. Oxytocin solution versus expectant management UVI of oxytocin solution might slightly reduce in the need for manual removal compared with expectant management (mean RR 0.73, 95% CI 0.56 to 0.95; 7 studies, n = 546; low-certainty evidence). There may be little to no difference between the incidence of blood transfusion between groups (RR 0.81, 95% CI 0.47 to 1.38; 4 studies, n = 339; low-certainty evidence). There were no maternal deaths reported (2 studies, n = 93). Evidence for severe postpartum haemorrhage of 1000 mL or greater, additional uterotonics, and infection was very-low certainty. There were no events for postpartum anaemia (24 to 48 hours postnatal). Oxytocin solution versus saline solution UVI of oxytocin solution may reduce the use of MROP compared with saline solution, but there was high heterogeneity (RR 0.82, 95% CI 0.69 to 0.97; 14 studies, n = 1370; I² = 54%; low-certainty evidence). There were no differences between subgroups according to risk of bias or oxytocin dose for the outcome MROP. There may be little to no difference between groups in severe postpartum haemorrhage of 1000 mL or greater, blood transfusion, use of additional therapeutic uterotonics, and antibiotic use. There were no events for postpartum anaemia (24 to 48 hours postnatal) (very low-certainty evidence) and there was only one event for maternal mortality (low-certainty evidence). Oxytocin solution versus plasma expander One small study reported UVI of oxytocin compared with plasma expander (n = 109). The evidence was very unclear about any effect on MROP or blood transfusion between the two groups (very low-certainty evidence). No other primary outcomes were reported. For other comparisons there were little to no differences for most outcomes examined. However, there was some evidence to suggest that there may be a reduction in MROP with prostaglandins in comparison to oxytocin (4 studies, n = 173) and ergometrine (1 study, n = 52), although further large-scale studies are needed to confirm these findings. AUTHORS' CONCLUSIONS: UVI of oxytocin solution is an inexpensive and simple intervention that can be performed when placental delivery is delayed. This review identified low-certainty evidence that oxytocin solution may slightly reduce the need for manual removal. However, there are little or no differences for other outcomes. Small studies examining injection of prostaglandin (such as dissolved misoprostol) into the umbilical vein show promise and deserve to be studied further.

Early versus late hysteroscopic resection after high-intensity focused ultrasound for retained placenta accreta.

Objective: To compare early and late hysteroscopic resection after high-intensity focused ultrasound (HIFU) for retained placenta accreta. Methods: This retrospective study included 63 women with retained placenta accreta who were treated with HIFU combined with hysteroscopic resection. They were divided into an early group (n = 40) and a late group (n = 23), depending on the time between the HIFU and the hysteroscopic resection. The number of sessions of hysteroscopy needed, adverse events, menstrual recovery, and reproductive outcomes were compared. Results: The mean largest diameter of the retained placenta accreta was 67.6 ± 14.0 mm and 71.6 ± 23.6 mm in each group (p = .47), respectively. In the early group, the first hysteroscopic procedure was done at a mean interval of 2.7 ± 1.4 days after HIFU ablation, while in the late group, the interval was 34.7 ± 15.0 days (p < .001). The rate of complete resection of placenta residue after one hysteroscopic procedure in the late group was 73.9% (17/23). This was significantly higher than in the early group, where the rate was 45% (p = .03). During the follow-up, there was no difference in menstrual recovery and pregnancy outcomes between the groups. Conclusion: This study was the first to compare the effects and safety of early and late hysteroscopic resection after HIFU for retained placenta accreta. Late hysteroscopic resection seems to increase the rate of complete resection of retained placenta accreta after one hysteroscopic procedure.

Treatment protocols and management of retained fetal membranes in cattle by rural practitioners in Belgium.

Retained fetal membranes (RFM) is a frequent postpartum disorder in cattle causing considerable economic losses, and a common indication for antibiotic (AB) administration. There is controversy with regard to the treatment of RFM, and scientific recommendations are often in conflict with current legislation on AB use and practical routines in the field. The aim of this study was to assess the therapeutic approaches of RFM by Belgian rural veterinarians. A digital survey was sent to 468 Belgian veterinarians; 149 complete questionnaires (Wallonia: 78; Flanders: 71) were obtained. Survey questions captured socio-demographic characteristics, case definition, therapeutic approaches and treatment options for RFM. Questions on treatment were duplicated for dairy and beef cattle. When confronted with dairy cows suffering from RFM without fever, 35.6 % of vets do not treat with AB, while the majority administers AB, either intrauterine (47.6 %), systemically (10.7 %) or both (6.1 %). Dairy cows with RFM and fever receive a systemic (33.5 %), intrauterine (2.7 %) or combined (61.8 %) AB treatment. For a beef cow with RFM without fever, 21.5 % of vets prefer no AB treatment, while others prefer an intrauterine (24.2 %), systemic (24.8 %), combined (29.5 %) AB treatment. Beef cows with RFM and fever receive AB from the large majority of vets, by systemic (34.9 %) or combined (56.3 %) administration. In case of a parenteral treatment, benzylpenicillin, amoxicillin and ampicillin are by far the most frequently used molecules; only a minority of vets use cephalosporins. Manual placental removal is attempted by 93.9 % of the respondents. These results demonstrate that there is room for improvement when considering the treatment protocols of RFM. Many veterinarians use AB in RFM cows not presenting symptoms of general illness, or administer intrauterine AB in cows with or without clinical signs of illness. Concerning the molecules of choice, practical routines are largely in line with national AB recommendations. Beef cows suffering from RFM are treated more rigorously than dairy cows, regardless of their rectal temperature.

Conservative management for adherent placenta after live birth in angular or interstitial pregnancies: A new entity "angular placenta attachment".

OBJECTIVE: Angular and interstitial pregnancies have been reported with live births and are often complicated by adherent placentas. Most cases had been treated with hysterectomy or corneal resection. CASE REPORT: We successfully treated four patients with conservative management (including one reported previously). Case 1 had a vaginal delivery, but the placenta remained attached. We maintained the patient under observation and delivered the placenta on postpartum day 9. Case 2 underwent a C-section. Uterine artery embolization controlled the hemorrhage without placenta removal. The placenta had disappeared by postpartum day 136. Case 3 underwent a C-section. The right uterine angle, where the placenta was attached, was bulging. We manually removed the placenta. CONCLUSION: We propose a new entity in angular or interstitial pregnancies called "angular placenta attachment" that could be diagnosed during C-sections or after vaginal delivery without placental separation. Expectant management may be considered for adherent placentas in these cases.

High-intensity focused ultrasound versus uterine artery embolization for patients with retained placenta accreta.

OBJECTIVE: To compare the safety and clinical effectiveness of high-intensity focused ultrasound (HIFU) and uterine artery embolization (UAE) for retained placenta accreta. STUDY DESIGN: A retrospective analysis was performed on women who underwent HIFU or UAE followed by hysteroscopic resection for retained placenta accreta from January 2015 to December 2019 at the Third Xiangya Hospital of Central South University. RESULTS: A total of 63 and 31 patients who underwent HIFU and UAE followed by hysteroscopic resection, respectively, were analyzed. The baseline characteristics, including age, gravidity, parity, previous cesarean section rate, previous curettage rate, previous intrauterine adhesions rate, and delivery mode, were similar between the two groups. Vaginal bleeding was the major complaint in patients with retained placenta accreta. The number of hysteroscopy sessions, amount of intraoperative blood loss, and the length of hospital stays were also similar between the groups. No further hysterectomy was needed in either group. CONCLUSION: Both HIFU and UAE combined with hysteroscopic resection seem to be safe and effective procedures in cases of retained placenta accreta.

Expectant management of retained abnormally adherent placenta complicated by uterine prolapse after vaginal delivery.

The placenta accreta spectrum (PAS) describes invasion and adherence of the placenta onto or beyond the myometrium. Prenatal imaging improves management outcomes. In low- and middle-income countries (LMIC), however, the unavailability of ultrasonography in some health facilities delays the diagnosis, particularly if the prenatal period is asymptomatic. Following vaginal delivery, it often manifests as failure to remove a retained placenta manually. In the absence of haemorrhage, expectant management involving leaving the placenta in situ, is an option. In the presence of haemorrhage and/or sepsis, hysterectomy is usually recommended. We present a case of an expectantly managed PAS following a spontaneous preterm vaginal birth. The patient developed puerperal uterine prolapse with the placenta in situ, a previously unreported complication, but this was successfully reduced manually.

Management of postpartum pulmonary embolism combined with retained placenta accreta: A case report.

RATIONALE: Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta. PATIENT CONCERNS: A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta. DIAGNOSES: The patient was diagnosed with the infection, postpartum PE, and residual placenta. INTERVENTIONS: The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy. OUTCOMES: The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy. LESSONS: Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.

Fetal Membrane Removal in the Mare: Proactive Versus Reactive Approaches.

Retained fetal membranes are the most common postpartum condition in mares. Although the incidence of retained fetal membranes is low, the consequences for the health of the mare can be severe (metritis, endotoxemia, laminitis, death). Oxytocin administration is often the first line of therapy for management of retained fetal membranes. Removal of fetal membranes using umbilical vessel infusion and manual membrane removal are effective tools for reducing risks associated with abnormally heavy membranes, retained membranes, or for mares that are geographically limited for veterinary care.

Conservative management of retained products of conception in the normal placental position: A retrospective observational study.

OBJECTIVES: To clarify the outcome of retained products of conception (RPOC) without placenta previa. STUDY DESIGN: This was a retrospective cohort study consisting of 59 patients who abdominally or vaginally gave birth to infants after 14 weeks without placenta previa and had RPOC between April 2006 and December 2018. Patients' background, characteristics, and outcomes were compared between those requiring and not-requiring intervention for RPOC. RESULTS: Of the 59 patients, pregnancies after assisted reproductive technology accounted for 18 (31%). The ultrasound-measured RPOC length was 4 cm (median) and 39 (66%) showed hypervascularity within RPOC. Interventions were required in 36 patients (61%), with all due to bleeding-related events. Multivariate regression analyses revealed that the interventions were significantly more likely in the following situations: younger than 35 years (aOR: 4.2, 95%CI: 1.1-18.5), RPOC length ≥4 cm (aOR: 8.6, 95%CI: 2.4-39.2), and RPOC hypervascularity (aOR: 4.6, 95%CI: 1.3-18.8). Methotrexate was administered to 8 patients, of whom 4 (50%) required further hemostatic interventions. CONCLUSION: In patients with RPOC without previa, 61 and 39% did and did not require hemostatic interventions, respectively. In the latter, a wait-and-see strategy resulted in the resolution of RPOC. Patients with larger RPOC (≥4-cm fragment length) and hypervascularity were significantly more likely to require hemostatic intervention.

Public provision of emergency obstetric care: a case study in two districts of Pakistan.

OBJECTIVES: Pakistan is one out of five countries where together half of the global neonatal deaths occur. As the provision of services and facilities is one of the key elements vital to reducing this rate as well as the maternal mortality rate, this study investigates the status of the delivery of essential obstetric care provided by the public health sector in two districts in Khyber Pakhtunkhwa in 2015 aiming to highlight areas where critical improvements are needed. SETTING: We analysed data from a survey of 22 primary and secondary healthcare facilities as well as 85 community midwives (CMWs) in Haripur and Nowshera districts. PARTICIPANTS: Using a structured questionnaire we evaluated the performance of emergency obstetric care (EmOC) signal functions and patient statistics in public health facilities. Also, 102 CMWs were interviewed about working hours, basic and specialised delivery service provision, referral system and patient statistics. PRIMARY OUTCOME MEASURES: We investigate the public provision of emergency obstetric care using seven key medical services identified by the United Nations (UN). RESULTS: Deliveries by public health cadres account for about 30% of the total number of births in these districts. According to the UN benchmark, only a small fraction of basic EmOC (2/18) and half of the comprehensive EmOC (2/4) facilities of the recommended minimum number were available to the population in both districts. Only a minority of health facilities and CMWs carry out several signal functions. Only 8% of the total births in one of the study districts are performed in public EmOC health facilities. CONCLUSIONS: Both districts show a significant shortage of available public EmOC service provisions. Development priorities need to be realigned to improve the availability, accessibility and quality of EmOC service provisions by the public health sector alongside with existing activities to increase institutional births.

Analysis of prophylactic Bakri balloon tamponade failure in patients with placenta previa.

OBJECTIVE: Recently, Bakri balloon (BBT) was effective for women with placenta previa to reduce hemorrhage. However, about 10% of women needed to receive an invasive strategy. Thus, the identification of risk factors and the development of additional measurements for BBT failure was needed. The aim of our study is to investigate the cause and measurements of failing prophylactic BBT in women with placenta previa. MATERIALS AND METHODS: Women with placenta previa who underwent cesarean section and had a prophylactic BBT inserted during the operation at our institution between January 2015 and December 2017 were enrolled. Patients requiring additional procedures after cesarean section for massive hemorrhage were defined as BBT failures. Additionally, the patterns and risk factors of BBT failure were retrospectively evaluated. RESULTS: Seventy women met the inclusion criteria. Of them, 9 (13%) were in the balloon failure group and 61 (87%), in the balloon success group. Between two groups, the median of postoperative blood loss was 1153 g vs. 70 g (p < 0.01) and the total blood loss 2409 g vs. 971 g (p < 0.01). There were two types of failures in the balloon failure group: balloon prolapse in eight patients (89%) and accidental placental retention in one patient (11%). The hemorrhage was controlled in all patients with balloon prolapse by reinsertion and inflation of the balloon. The patient with placental retention required a uterine artery embolization (UAE). Although three patients required a blood transfusion, none required a hysterectomy. The logistic regression for the risk of balloon failure revealed classification of major previa to be the highest risk factor (Hazard Ratio; 19.1, 95% Confidence Interval; 3.17-367.9, p < 0.01). CONCLUSION: The major cause of BBT failure was balloon prolapse. It could be treated with non-invasive methods; however, patients with placental retention could not avoid invasive treatment to stop the hemorrhage.

Management of the third stage of labor in second-trimester deliveries: How long is too long?

BACKGROUND: Retained placenta is the most common second-trimester delivery complication. As the optimal third stage of labor duration remains undefined, complications associated with retained placentas are difficult to study. OBJECTIVE(S): To determine the optimal third stage of labor duration in second-trimester deliveries based on estimates of time-specific probabilities of placental delivery, placental intervention, and postpartum complication. STUDY DESIGN: We retrospectively studied adult women with singleton second-trimester vaginal deliveries. We identified third stage of labor duration, placental delivery method (spontaneous vs. manual/operative intervention), and indication for intervention. Postpartum complication was examined as a composite outcome. Differences among groups defined by delivery method and postpartum complication were tested using parametric and nonparametric tests. Probability curves describing the time-specific probabilities of placental delivery were derived using lifetable methods with group differences tested using the log-rank test. Probability of placental intervention and complication by time to placental delivery were examined using logistic regression with adjustment for confounders and other predictors. RESULTS: We identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P < 0.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P < 0.01). At 2 h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2 h following fetal delivery. Patients with PPROM would require intervention by 34 min, and those with intrapartum fever or delivery EBL ≥500 mL would already exceed the risk threshold at fetal delivery. CONCLUSIONS: Our study suggests that an optimal third stage of labor duration of approximately 2 h maximizes probability of spontaneous delivery and minimizes complication risk. Timing of intervention may be further individualized for patients based on maternal characteristics and intrapartum conditions.

Manual removal of placenta in women having unpredictable adherent placenta.

AIM: Our aim is to provide expected outcomes for undergoing manual removal of placenta (MROP) following vaginal delivery in women having an unpredictable adherent placenta (AP). METHODS: The data were obtained from four hospitals in Miyazaki Prefecture, Japan. We used propensity score-matched (1:1) analysis to match women who underwent MROP with women who did not undergo MROP (control). Total blood loss and hemorrhagic rate used as a ratio of women who reached a certain amount of blood loss were compared. Subgroup analysis was undertaken and was dependent on the presence of AP. We found the cut-off value of blood loss for detecting AP. RESULTS: Thirty-seven MROP cases were identified. Total blood loss and hemorrhagic rate differed significantly between MROP cases and controls; 95% of controls had blood loss of 1000 mL or less, whereas for the MROP cases, it was 14%. Fourteen MROP cases were diagnosed with AP. The hemorrhagic rate differed significantly between MROP cases with and without AP (n = 19); 79% of MROP cases without AP had blood loss of 2000 mL or less, whereas for the MROP cases with AP, it was 7%. There were seven incidents of hysterectomy and two of arterial embolization in MROP cases with AP. Through receiver operating characteristic curve analysis, 2035 mL of blood loss was determined to be the optimal cut-off value for detecting AP. CONCLUSION: The incidence of unpredictable AP in MROP cases was as high as 38%. The morbidity of MROP cases with unpredictable AP was severe. MROP should be prohibited in the absence of appropriate hemostatic preparations.

Association of Implementing a Multidisciplinary Team Approach in the Management of Morbidly Adherent Placenta With Maternal Morbidity and Mortality.

OBJECTIVE: To compare maternal outcomes in patients with morbidly adherent placenta managed in a multidisciplinary team setting compared with standard care. DATA SOURCES: A literature search was performed for publications reporting multidisciplinary pathways in the management of cesarean delivery for patients with morbidly adherent placenta. EMBASE, MEDLINE, PubMed, PubMed Central, ClinicalTrials.gov, and Cochrane databases were searched. METHODS OF STUDY SELECTION: Databases were searched for studies reporting maternal morbidity of patients with morbidly adherent placenta managed by a multidisciplinary team in a specialist center compared with standard care. Two independent reviewers applied inclusion and exclusion criteria to select included articles, with differences agreed by consensus. A total of 252 citations were reviewed; six studies comprising 461 patients were selected for the analysis. TABULATION, INTEGRATION, AND RESULTS: Literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results were reported as mean differences or pooled odds ratios (ORs) with 95% CIs. Estimated blood loss was significantly reduced in the multidisciplinary team group (mean difference -1.1 L, 95% CI -1.9 to -0.4, P=.004) and these patients had lower transfusion requirements (mean difference -2.7 units, 95% CI -4.1 to -1.2, P=.040). Those treated in a standard care setting were more likely to develop complications (OR 2.5, 95% CI 1.5-4.0, P<.001); however, there was no difference in length of stay between the two groups. CONCLUSION: This meta-analysis highlights the improved maternal outcomes in patients with morbidly adherent placenta when managed by a multidisciplinary team in a specialist center. High-risk complex cases warrant expert management in centralized units.