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.

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.

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.

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.

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.

Surgical and Reproductive Outcomes after Hysteroscopic Removal of Retained Products of Conception: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the impact of hysteroscopy for retained products of conception (RPOC) removal on surgical and reproductive outcomes. DATA SOURCES: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, SciELO, EMBASE, and the Cochrane Central Register of Controlled Trials at the Cochrane Library) were searched from inception to March 2020. METHODS OF STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Medical Subject Headings terms and text words such as "retained products of conception," "placental remnants," "placenta," and "hysteroscopy" were used for the identification of relevant studies. We included observational and randomized studies that analyzed surgical and/or reproductive outcomes of women who underwent hysteroscopic removal of RPOC. The primary outcome was the complete resection rate after 1 procedure. TABULATION, INTEGRATION, AND RESULTS: Twenty out of 245 studies were applicable, with data provided for 2112 women. The pooled complete resection rate was 91% (95% confidence interval [CI], 0.83-0.96). The incomplete resection rate evaluated was 7% (95% CI, 0.03-0.14), with a complication rate of 2% (95% CI, 0.00-0.04). Out of 1478 procedures, only 12 cases (0.8%) of postsurgical intrauterine adhesions were reported. Regarding post-therapy fecundity, women attempting postoperative conception had a clinical pregnancy rate of 87% (95% CI, 0.75-0.95), with a live birth rate of 71% (95% CI, 0.60-0.81) and a pregnancy loss rate of 9% (95% CI, 0.06-0.12). CONCLUSION: Hysteroscopy has a high rate of completely removing RPOC in a single surgical step, with low complication rates. Subsequent fecundity seems reassuring, with appropriate clinical pregnancy and live birth rates. However, standardization of approach and comparative trials of different hysteroscopic approaches are needed.

Association Between First-Trimester Bleeding and Retained Placenta Requiring Dilatation and Curettage.

OBJECTIVE: Early subchorionic hemorrhage may lead to a disruption in the placental-uterine matrix, which may result in an adherence of the placenta to the endometrium. We evaluated the effect of a first-trimester bleed on the need for a post-vaginal delivery dilatation and curettage (D&C) for removal of retained placenta. METHODS: We conducted a case-control study at a tertiary care centre between 2012 and 2016. Patients identified through medical records as having required a post-vaginal delivery D&C for retained placenta were considered cases and were matched 1:5 with patients delivering vaginally within 1 week who did not require a D&C. History of first-trimester bleeding and subchorionic hemorrhage were identified through chart review. Conditional logistic regression analyses estimated the effect of a first-trimester bleed on the requirement for D&C for retained placenta. Models were adjusted for maternal age and previous uterine surgery. RESULTS: There were 68 cases of retained placenta requiring D&C, for an estimated 3 in 1000 deliveries. Patients requiring D&C were slightly older than controls but were otherwise comparable with respect to baseline demographic characteristics. In adjusted analyses, patients who required a postpartum D&C were more likely than controls to have had a first-trimester bleed at 11.8% and 0.6%, respectively (OR 25.3; 95% CI 4.7-135.4, P < 0.001). Postpartum D&C for retained placenta was associated with postpartum hemorrhage, need for blood transfusion, and manual removal of placenta. CONCLUSION: First-trimester bleeding should be considered a high-risk determinant for post-vaginal delivery D&C for retained placenta and for severe postpartum hemorrhage.

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.

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.

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.

Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data.

OBJECTIVE: To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH). DESIGN: Secondary analysis of the WHO CHAMPION trial data. SETTING: Twenty-three hospitals in ten countries. POPULATION: Women from the CHAMPION trial who received uterotonics as first-line treatment of PPH. METHODS: We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first-line PPH treatment. MAIN OUTCOME MEASURES: Maternal characteristics; causes of PPH. RESULTS: Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34-2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04-1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively. CONCLUSION: Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first-line treatment responsive PPH. TWEETABLE ABSTRACT: Women with refractory postpartum haemorrhage are different from those with first-line treatment responsive PPH.

Placental location and risk of retained placenta in women with a previous cesarean section: A population-based cohort study.

INTRODUCTION: Some studies have shown that women with a previous cesarean section, compared with women with a previous vaginal delivery, have an increased risk of retained placenta during a subsequent vaginal delivery. It is unknown whether this is mediated by anterior placental location, when the placenta might cover the uterine scar. The aim of this study was to evaluate whether the increased risk of retained placenta in women with a previous cesarean section is mediated by anterior placental location. MATERIAL AND METHODS: This is a population-based cohort study, with data from the regional population-based Stockholm-Gotland Obstetric Cohort, Sweden, from 2008 to 2014. The overall study population included 49 598 women with a vaginal second delivery, where adequate information about placental location from the second-trimester ultrasound scan was available. For the main analysis, including the 3921 women with a previous cesarean section, we calculated the relative risk of retained placenta in women with an anterior placental location, using women with non-anterior placental locations as reference. Relative risks were calculated as odds ratios (OR) with 95% CI. In a second model, adjustments were made for maternal age, height, country of birth, smoking in early pregnancy, infant sex, and in vitro fertilization. RESULTS: In the overall study population, the rate of retained placenta at the second delivery was 2.0%. The proportion of women with a retained placenta was higher among women with a previous cesarean compared with those with a previous vaginal delivery (3.4% vs 1.9%; P < .0001). In the main analysis, including women with a previous cesarean section, the risk for retained placenta was not increased with anterior compared with non-anterior placental location (OR 0.84, 95% CI 0.60-1.20). Adjustments did not affect the estimates in a significant way. CONCLUSIONS: The increased risk of retained placenta in women with a previous cesarean section is not mediated by anterior placental location.

Early-lactation diseases and fertility in 2 seasons of calving across US dairy herds.

The objective of this study was to characterize incidences of health disorders during early lactation in a large population of Holstein cows calving in 2 seasons across multiple US dairy herds. In addition, cumulative effects of combinations of health-related events on fertility and survival by season of calving and parity number were tested. Data were prospectively collected from a total of 11,729 cows in 16 herds located in 2 regions in the United States [north (7,820 cows in 10 herds) and south (3,909 cows in 6 herds)]. Cows were enrolled at parturition and monitored weekly for disease occurrence, reproductive events, and survival. Health-related events were grouped into reproductive disorders (REP; dystocia, twins, retained fetal membranes, metritis, and clinical endometritis) and other disorders (OTH; subclinical ketosis, mastitis, displaced abomasum, and pneumonia). Counts of health events within 50 d postpartum were added into each of the groups and categorized as 0, 1, 2, 3, and ≥4 for REP and 0, 1, 2, and ≥3 for OTH. Multivariable logistic regression was used for testing potential associations between categories of disease occurrence and outcome variables, including resumption of ovarian cyclicity, pregnancy per artificial insemination (AI), pregnancy loss, and survival up to and after 50 DIM. The incidence of disease varied with season of calving and parity, and these 2 variables were associated with the reproductive and survival outcomes. The size of the detrimental effect of disease incidence on reproduction and survival depended on disease group and varied for each specific outcome. Resumption of ovarian cyclicity decreased as incidences of disorders increased in both REP and OTH categories. Pregnancy at first AI also was smaller in greater number of REP categories, but the effect of number of OTH categories on pregnancy at first AI was not consistent. Similarly, pregnancy loss at first AI was not affected consistently by REP or OTH. Survival was reduced by REP and OTH. The magnitude of these negative effects was variable, depending on season of calving and parity, but consistently increased with the number of health events during early lactation.

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.

The Placenta Accreta Spectrum: Epidemiology and Risk Factors.

The placenta accreta spectrum has become an important contributor to severe maternal morbidity. The true incidence is difficult to ascertain, but likely falls near 1/1000 deliveries. This number seems to have increased along with the rate of risk factors. These include placenta previa, previous cesarean section, use of assisted reproductive technologies, uterine surgeries, and advanced maternal age. With increased uterine conservation, previous retained placenta or placenta accreta have become significant risk factors. Understanding placenta accreta spectrum risk factors facilitates patient identification and safe delivery planning. Patients considering elective uterine procedures or delayed childbirth should consider the impact on peripartum morbidity.

Pregnancy Outcomes after Endometrial Ablation in a Multi-institutional Cohort.

OBJECTIVE: The objective of this study was to determine the incidence of morbidly adherent placenta in pregnancies after endometrial ablation. STUDY DESIGN: We performed a retrospective cohort analysis using a large, multiinstitutional deidentified clinical database, IBM EPM: Explore (IBM Corporation, Somers, NY). We identified women who underwent endometrial ablation and had a subsequent delivery between 1999 and 2016. Patients with a delivery and no prior ablation were used as controls. The association between morbidly adherent placenta, ablation, and other known risk factors for morbidly adherent placenta was analyzed using multivariable logistic regression. RESULTS: Of 162,100 reproductive-aged women who underwent endometrial ablation, 2,770 women (1.71%) subsequently had a delivery. The rate of morbidly adherent placenta was 1 in 13.9 pregnancies after ablation compared with 1 in 838.7 pregnancies in the control group (adjusted odds ratio [aOR], 20.22, p < 0.0001). CONCLUSION: Pregnancies that occurred after endometrial ablation were associated with increased rates of morbidly adherent placenta.

Effects of intrauterine infusion of Escherichia coli lipopolysaccharide on uterine health, resolution of purulent vaginal discharge, and reproductive performance of lactating dairy cows.

The objectives of the current experiment were to evaluate the effects of intrauterine infusion of Escherichia coli lipopolysaccharide (LPS) in cows diagnosed with purulent vaginal discharge (PVD) on intrauterine cell population, resolution of PVD, uterine health, and reproductive performance. Jersey cows (n = 3,084) were examined using the Metricheck device to diagnose PVD at 35 ± 6 d postpartum. Purulent vaginal discharge was defined as the presence of purulent (≥50% pus) discharge detectable in the vagina. Of the 310 cows positive for PVD, 267 cows were enrolled in the current experiment. To ensure proper timing of treatment and collection of samples, only 9 PVD-positive cows were treated per day. Selected cows were balanced at 35 ± 6 d postpartum for lactation number, body condition score, and milk yield and were randomly assigned to receive an intrauterine infusion of 20 mL of phosphate-buffered saline (PBS; control, n = 87), 20 mL of PBS with 150 µg LPS (LPS150, n = 91), or 20 mL of PBS with 300 µg of LPS (LPS300, n = 89). Uterine cytology was performed immediately before treatment and 1, 2, and 7 d after treatment to evaluate the effect of LPS treatment on intrauterine cell population. Cows were examined with the Metricheck device at 7 and 28 d after treatment to evaluate the effects of treatment on resolution of PVD. Reproductive status was recorded up to 200 d postpartum. Cows diagnosed with PVD had greater incidence of twinning, dystocia, retained placenta, and metritis after calving than cows without PVD. Count of polymorphonuclear leukocytes (PMNL) in uterine cytology 1, 2, and 7 d after intrauterine infusion was not statistically different among treatments. From d 0 to 1, however, PMNL count in uterine cytology of PBS cows increased by 5%, whereas the PMNL count in uterine cytology of LPS150 and LPS300 cows increased by 54 and 48%, respectively. Treatment did not affect the likelihood of cows being diagnosed with PVD 7 and 28 d after intrauterine infusion. Cows without PVD and LPS150 cows were more likely to be pregnant after the first postpartum AI than PBS cows. After the second postpartum AI, cows without PVD were more likely to be pregnant than PBS and LPS300 cows. Hazard of pregnancy up to 200 d postpartum was decreased for PBS and LPS300 cows compared with cows without PVD, and it tended to be decreased for LPS150 cows compared with cows without PVD. Intrauterine treatment with 150 µg of E. coli LPS of cows diagnosed with PVD improved likelihood of pregnancy after the first postpartum AI, but further research is needed to elucidate the mechanism by which LPS treatment improved fertility.

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.

Breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour.

BACKGROUND: Oxytocin and prostaglandin are hormones responsible for uterine contraction during the third stage of labour. Receptors in the uterine muscles are stimulated by exogenous or endogenous oxytocin leading to uterine contractions. Nipple stimulation or breastfeeding are stimuli that can lead to the secretion of oxytocin and consequent uterine contractions. Consequently, uterine contractions can reduce bleeding during the third stage of labour. OBJECTIVES: To investigate the effects of breastfeeding or nipple stimulation on postpartum haemorrhage (PPH) during the third stage of labour. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 July 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing breast stimulation, breastfeeding or suckling for PPH in the third stage of labour were selected for this review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion in terms of risk of bias and independently extracted data. Disagreements were resolved by a third review author. MAIN RESULTS: We included four trials (4608 women), but only two studies contributed data to the review's analyses (n = 4472). The studies contributing data were assessed as of high risk of bias overall. One of these studies was cluster-randomised and conducted in a low-income country and the other study was carried out in a high-income country. All four included studies assessed blood loss in the third stage of labour. Birth attendants estimated blood loss in two trials. The third trial assessed the hematocrit level on the second day postpartum to determine the effect of the bleeding. The fourth study measured PPH ≥ 500 mL. Nipple stimulation versus no treatmentOne study (4385 women) compared the effect of suckling versus no treatment. Blood loss was not measured in 114 women (59 in control group and 55 in suckling group). After excluding twin pregnancies, stillbirths and neonatal deaths, the main analyses for this trial were performed on 4227 vaginal deliveries. In terms of maternal death or severe morbidity, one maternal death occurred in the suckling group due to retained placenta (risk ratio (RR) 3.03, 95% confidence interval (CI) 0.12 to 74.26; one study, participants = 4227; very low quality evidence); severe morbidity was not mentioned. Severe PPH (≥ 1000 mL) was not reported in this study.The incidence of PPH (≥ 500 mL) was similar in the suckling and no treatment groups (RR 0.95, 95% CI 0.77 to 1.16; one study, participants = 4227; moderate quality). There were no group differences between nipple stimulation and no treatment regarding blood loss in the third stage of labour (mean difference (MD) 2.00, 95% CI -7.39 to 11.39; one study, participants = 4227; low quality). The rates of retained placenta were similar (RR 1.01, 95% CI 0.14 to 7.16; one study, participants = 4227; very low quality evidence), as were perinatal deaths (RR 1.06, 95% CI 0.57 to 1.98; one study, participants = 4271; low quality), and maternal readmission to hospital (RR 1.01, 95% CI 0.14 to 7.16; one study, participants = 4227; very low quality). We downgraded the evidence for this comparison for risk of bias concerns in the one included trial (inappropriate analyses for cluster design) and for imprecision (wide CIs crossing the line of no difference and, for some outcomes, few events).Many maternal secondary outcomes (including side effects) were not reported. Similarly, most neonatal secondary outcomes were not reported. Nipple stimulation versus oxytocinAnother study compared the effect of nipple stimulation (via a breast pump) with oxytocin. Eighty-seven women were recruited but only 85 women were analysed. Severe PPH ≥ 1000 mL and maternal death or severe morbidity were not reported.There was no clear effect of nipple stimulation on blood loss (MD 15.00, 95% CI -24.50 to 54.50; one study, participants = 85; low quality evidence), or on postnatal anaemia compared to the oxytocin group (MD -0.40, 95% CI -2.22 to 1.42; one study, participants = 85; low quality evidence). We downgraded evidence for this comparison due to risk of bias concerns in the one included trial (alternate allocation) and for imprecision (wide CIs crossing the line of no difference and small sample size).Many maternal secondary outcomes (including side effects) were not reported, and none of this review's neonatal secondary outcomes were reported. AUTHORS' CONCLUSIONS: None of the included studies reported one of this review's primary outcomes: severe PPH ≥ 1000 mL. Only one study reported on maternal death or severe morbidity. There were limited secondary outcome data for maternal outcomes and very few secondary outcome data for neonatal outcomes.There was no clear differences between nipple stimulation (suckling) versus no treatment in relation to maternal death, the incidence of PPH (≥ 500 mL), blood loss in the third stage of labour, retained placenta, perinatal deaths or maternal readmission to hospital. Whilst these data are based on a single study with a reasonable sample size, the quality of these data are mostly low or very low.There is insufficient evidence to evaluate the effect of nipple stimulation for reducing postpartum haemorrhage during the third stage of labour and more evidence from high-quality studies is needed. Further high-quality studies should recruit adequate sample sizes, assess the impact of nipple stimulation compared to uterotonic agents such as syntometrine and oxytocin, and report on important outcomes such as those listed in this review.