RETAINED PLACENTA

Introduction-
The third stage of labour is defined as the period after delivery of the baby to
complete delivery of the placenta. So basically the placenta is delivered in the third
stage and a delay in delivery of the placenta after a normal vaginal delivery beyond
the stipulated time is termed as retained placenta. This time limit after which we call
it retained placenta varies according to how the third stage of labour has been
managed and the gestational age at delivery.
When active management of third stage of labor has been done 98% of the placenta
are delivered within 30 minutes and in contrast to this in physiological management
of 3rd stage it takes 60 minutes for delivery of 98% of the placenta (1). In preterm
gestation it takes longer for the placenta to be delivered especially in the 2 nd
trimester deliveries (2).
Definition-
WHO suggests that the time period after which we call it a retained placenta should
be “left to the judgement of clinician”(3). How much at least ?
Incidence-
It varies from 0.1- 3%. The incidence is more in physiological management of 3 rd
stage of labour as compared to active management. The incidence also increase in
preterm deliveries, being 3times higher and in 2 nd trimester the risk increases 21-fold.
Above lines here
Phases of 3rd stage of labour-
4 phases of 3rd stage of labour have been defined based on Ultrasound findings (4)
1. Latent phase- In this after delivery of the baby, the myometrium contracts all
over except the site of placental attachment.
2. Contraction phase- Myometrium at the site of placental attachment contracts.
3. Detachment phase- Because of the myometrial contraction, there is a
shearing force on the placental surface, thus leading to its separation.
4. Expulsion phase- The separated placenta is pushed out through the open
cervix because of the myometrial contractions.
Pre-requisites for spontaneous delivery of the placenta-
1. Adequate uterine contraction
2. Cervix should be open
3. Placenta should be normally attached to the endometrium WITH INTERFACE
WHICH IS ? CM ON USG

Types of Retained Placenta and their pathogenesis-

1. Trapped or Incarcerated placenta – In this a completely separated placenta is
trapped behind a closed cervix as in case of administration of Ergotamine
derivative which causes tetanic contraction of the uterus and cervix, so defect in
expulsion phase. This accounts for approximately 18% of all the retained
placenta.

2. Placenta adherens – In this the placenta is adherent to uterine wall but can be
easily separated manually. In this there is defect in the contraction phase
because of which the placenta does not separate. This accounts for nearly 81%
of the cases.

3. Placenta Accreta Spectrum- This is a structural defect in which there is invasion

of the placenta into the myometrium in varying degrees and extent. This
accounts for nearly 6% of all the cases.

Risk Factors- CAN WE MAKE A CHART I MEAN TABLE TYPE WITH

BULLETS
1. Factors causing entrapment of separated placenta-
Use of Ergotamines
Mismanaged 3rd stage of labour- Attempts of cord traction before signs of
placental separation.
Preterm Deliveries- especially 2nd trimester deliveries are the strongest risk
factor.
Velamentous cord insertion
2. Factors causing poor uterine contraction ( Placenta Adherens)-SPELL CHECK
Maternal age >30 yrs
Multiparity
Prolonged use of oxytocin making the myometrium tired and loosing its strength
to contract
3. Factors causing Abnormal placentation (Placenta Accreta Spectrum)-
Previous uterine surgeries- Previous LSCS, Curettage, Myomectomy
Advanced Maternal age
IVF conception
4. Other risk Factors-
Congenital uterine anomalies- Incomplete uterine septum seen in many cases
of retained placenta
History of retained placenta in previous pregnancies- It increases the risk to
25%.
Placental Hypoperfusion Disorders- as seen in Pre-eclampsia, Fetal Growth
Restrictions, Stillbirths. The pathophysiology is not known.
 Factors causing entrapment  Use of Ergotamines
of separated placenta-  Mismanaged 3rd stage of labour- Attempts of cord traction
before signs of placental separation.
 Preterm Deliveries- especially 2nd trimester deliveries are
the strongest risk factor.
 Velamentous cord insertion

Factors causing poor  Maternal age >30 yrs

uterine contraction  Multiparity
( Placenta Adherens )-  Prolonged use of oxytocin making the myometrium tired
and losing its strength to contract

Factors causing Abnormal  Previous uterine surgeries- Previous LSCS, Curettage,

placentation (Placenta Myomectomy
Accreta Spectrum)-  Advanced Maternal age
 IVF conception

Other risk Factors-  Congenital uterine anomalies- Incomplete uterine septum

seen in many cases of retained placenta
 History of retained placenta in previous pregnancies- It
increases the risk to 25%.
 Placental Hypoperfusion Disorders- as seen in Pre-
eclampsia, Fetal Growth Restrictions, Stillbirths. The
pathophysiology is not known.

Diagnosis-
Diagnosis of retained placenta is made when the placenta is not delivered even after
30 minutes of the delivery of the baby after active management of 3 rd stage of labour
in term gestation. The management of retained placenta depends on the type so we
need to define the type of retained placenta. The diagnosis is made on the basis of
clinical findings, which has been explained by the flowchart 1.
 Clinical signs of Placental Separation
(Sudden gush of blood, Permanent Lengthening of cord,
Uterine contraction and increase in fundal height)

Flowchart-1 spell

Ultrasound is rarely required to make the diagnosis, when physical

examination is non conclusive.
Trapped Placenta- The entire myometrium is thickened and placenta can be seen
separate from the uterine wall in the lower segment.
Adherent Placenta-
PRESENT The myometrium at the site of placental
ABSENT attachment can be seen
as thin in contrast to the rest of the myometrium which is thickened and placenta
cannot be seen separate from the uterine wall.
Complications-
Placental edge palpated by ATTEMPT MANUAL REMOVAL
examining fingers through cervix
 1. Postpartum Haemorrhage- Retained placenta increases the risk of
haemorrhage and requires prompt intervention.
2. Shock- This can be either because of haemorrhage or because of too much
abdominal or intrauterine manipulation.
3. Postpartum Endometritis- Manual removal of the placenta increases the risk
and so WHO recommends a dose of prophylactic broad spectrum antibiotics,
Ampicillin or a first generation Cephalosporin.
4. Uterine inversion- It is a rare complication seen if adherent placenta is
inadvertently pulled.
Management-
Do active management of 3rd stage of labour if not already done- Administer 10 units
of oxytocin, do controlled cord traction (Brandt Andrews technique).
Empty the bladder.

If Placenta NOT Delivered

Examine the patient, look for signs of Placental separation and based on the findings
make diagnosis of the type of retained placenta. Based on the type of retained
placenta further management is done, as explained in the following flowchart 2.
1.Trapped Placenta

Uterus contracted, os closed

Uterus relaxed

Flowchart- 2.
Give oxytocics Uterine relaxation with Glyceryl
trinitrate*
*Dose of Glyceryl trinitrate-
Spray- 2 spray (400 mcg/spray) onto/under the tongue

Attempt controlled cord Attempt controlled cord traction

traction

If Fails
 Sequential IV bolus- 50mcg repeated at 1 min interval (max 250 mcg)
Sublingual tablets- 0.6- 1mg.
Relaxation of the cervix and lower uterine segment occurs within 1 minute and lasts
for 1-2 minutes.
2.Placenta Adherens– The basic pathology is defective myometrial contraction in
the area of placental attachment. The management of Placenta Adherens has been
explained in the following flowchart 3.

Oxytocics are given to promote uterine contraction* (oxytocin 20 units in 500 ml of NS, IV
Infusion)

Controlled Cord Traction is done

If Fails

Manual Removal of Placenta is done

*1.Systemic Oxytocics-
Oxytocin 20 units in 500 ml of NS, IV infusion.
If uterus is still flabby and bleeding persists, Prostaglandin PGF2-alpha (Carboprost)
should be given.
Ergometrine should be avoided as it causes tetanic contraction of the uterus and
cervix and so will interfere with manual removal of placenta.
*2.Intra-umblical vein injection of oxytoics- This can be done through a nasogastric
tube size 10 inserted into the umblical vein spell . Through this either of the following
can be inserted-
- PGF2-alpha (20 mg in 20ml NS)
-Misoprostol (800 mcg in 30 ml NS)
-Oxytocin (50 units in 30 ml NS)
In various trials the intra-umblical injection of Oxytocin has not been found effective ,
so now WHO recommends that this be used only for the purpose of randomised
trials in the absence of heavy bleeding. There are few trials which show the
effectiveness of intra-umblical misoprost and carboprost but we need further studies
to prove them.

3.Placenta Accreta- If the plane of separation is not found then the diagnosis is
Placenta accreta. In this case in a female who has completed the family,
hysterectomy is the best approach. Conservative approach can be undertaken if the
patient is desirous to have further child bearing, but all the risks should be explained.
Its management has been dealt in separate chapter.
Special circumstances-
1. Retained placenta with heavy bleeding- In this case all the measures
should go hand in hand. Resuscitation should be started, Oxytocics should be
given, Controlled cord traction tried and along with this the patient should be
immediaditely shifted for manual removal of placenta. If the bleeding is still not
controlled then immediate laparotomy followed by hysterectomy may have to
be planned.
2. Incomplete placental extraction- During manual removal of the placenta a
small area may be very adherent to the uterus. In this case one should try to
dissect the area slowly with fingers which can cause the plane of separation
through the placenta, so a small area of placenta may be left attached to the
uterus. This usually does not cause bleeding if the uterus is well contracted.
Curettage should not be done here as the area of myometrium here is thin
and it increases the risk of perforation.

Steps of Manual Removal of the placenta-

As already discussed one should wait for 30 minutes for expulsion of the placenta
in a term gestation with active management of labour before planning for manual
removal of placenta, where as in 2nd trimester pregnancies one should wait for 90
to 120 minutes before attempting manual removal.
 This is a painful process with intra-uterine manipulation so it is always
done in OT under anaesthesia. General anaesthesia is given with
halothane for uterine relaxation.
 Prophylactic broad spectrum antibiotics should be given, Ampicillin or 1 st
generation cephalosporin with Metronidazole.
 Patient is placed in lithotomy position, parts painted and draped, bladder
catheterised.
 The umblical cord is held with left hand and stretched. The right hand is
introduced through the vagina, cervix into the uterine cavity in cone
shaped manner under aseptic precautions to reach for the margins of the
placenta.
 Now the left hand is placed over the fundus to support it and guide the
movement of intra-uterine fingers.
  The right hand is inserted between the placenta and the uterine wall with
the back of hand towards the uterine wall to find the plane of separation.
 Once the plane of separation is found, the hand is further advanced in
slicing manner by sideways movement to separate the whole placenta.
 The placenta is extracted with the left hand with uterine hand still inside
and the uterus is explored again to look for any placental tissue left
behind.
 The left hand is again placed on the fundus and the fundus is massaged to
promote uterine contraction.
 Oxytocin infusion is started (20 units in 500 ml of NS) to promote uterine
contractions.
 Cervicovaginal canal is explored to exclude any injury.
 Inspection of the placenta and membranes is done to check whether it is
complete or not.

Summary- CONCLUSION
 If active management of 3rd stage of labour has been done in a term
gestation, then if the placenta is not delivered within 30 minutes of delivery of
the baby we call it retained placenta whereas in 2 nd trimester deliveries the
wait time is 90-120 minutes
 The three types of retained placenta are- Trapped placenta (placenta
separated but trapped behind closed cervix), Placenta Adherens (placenta
adherent to uterine wall due to poor uterine contraction specially behind the
placenta, so can be separated), Placenta Accreta Spectrum (morbidly
adherent placenta, which cannot be separated).
 Trapped placenta is differentiated from adherent placenta by presence of
signs of placental separation.
 Placenta Accreta Spectrum, if not diagnosed in intranatal period can be
differentiated from Placenta Adherens only at the time of Manual removal.
 Trapped placenta can be removed just by control cord traction and if the os is
closed, glyceryl nitrate can be given for uterine relaxation.
 Placenta Adherens is managed by promoting uterine contraction by giving
oxytocics and then trying controlled cord traction.
 SPELL CHECK AND BETTER BULLTES AND POINTS

 Placenta Accreta spectrum is managed by hysterectomy in those who have
completed the family.
 Manual removal of placenta is done in OT under general anaesthesia.
 ADD REFERENCES ALSO
 SOME PICTURES IF THERE
 CARBITOCIN ????