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RETAINED
PLACENTA
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Failure of placental deliverywithin 30 minutesafterdeliveryofthefetus.
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Morbid Adherenceofthe placenta Placenta Acreta
Placenta Increta Placenta Percreta
Uterine Abnormality
Constriction Ring - reformingcervixFullbladder
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Ifthe placentaisundelivered after 30 minutesconsider: Emptyingbladder Breastfeedingornipplestimulation Changeof position - encourageanupright position
Ifbleeding:immediately Inform Anaesthetist Insertionoflargebore IV (18g)cannula Inserturinarycatheter Commence/continueoxytocininfusion 20 unitsin
1 litre/ rate 60drops per minMeasureand accuratelyrecord blood loss Prepareand transfer patienttotheatrefor
manualremovalof placenta (MROP)
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Introducingonehand intothevaginaalongcord
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Supportingthefundus whiledetachingthe placenta
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Withdrawingthehand fromtheuterus
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Observethe womancloselyuntiltheeffectof IV sedationhas wornoff.
Monitorthevitalsigns (pulse,bloodpressure,respiration)every 30minutesforthenext 6 hoursoruntilstable.
Palpatetheuterinefundustoensure
thattheuterusremainscontracted.Checkforexcessivelochia.Continueinfusionof IV fluids.Transfuseasnecessary.
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Shock
Postpartum haemorrhage Puerperal Sepsis
Subinvolution
Hysterectomy
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Umbilicalveininjectionofsalinesolutionplusoxytocinappearstobeeffectiveinthe managementofretained placenta.
Salinesolutionalone doesnotappearbemoreeffectivethanexpectantmanagement. The difficultiesinimplementingthisinterventionarerelatedtothetrainingof personnelinthetechniqueofgivinginjectionsintotheumbilicalvein.
TheWHO ReproductiveHealth Library, No 8, Oxford, 2005.The Cochrane Databaseof Systematic Reviews 2006 Issue 4
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The incidence of placenta accretahas increased 1010--foldfold in thein thepast 50 yearspast 50 years, to a currentfrequency of 1 per 2,5001 per 2,500
deliveriesdeliveries.largely as a result of the
increaseinthenumberofincreaseinthenumberofcesareansectionscesareansections
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Risk factors for placenta accreta include :1. placenta previa with or without previous
uterine surgery.2. previous myomectomy.3. previous cesarean delivery.4. Asherman's syndrome.5. submucous leiomyomata.6. maternal age of 36 years and older.
The ACOG committee
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Becauseofthefactthat manyofthesecasesbecomeevidentonlyat
thefirstattempttoseparatetheplacentaat delivery,itisessentialtoattempttoidentifyantenatally
both placentaaccreta and itsattendantriskfactors,the mostcommonof whichis concurrentconcurrentplacentaplacenta previaprevia & previous CS.& previous CS.
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characterized bycharacterized by aa hypoechoichypoechoic boundaryboundary
between the placenta and the urinarybetween the placenta and the urinarybladder that represents thebladder that represents the myometriummyometriumand normaland normal retroplacentalretroplacental myometrialmyometrialvasculature.vasculature.
The normal placenta has a homogenousThe normal placenta has a homogenousappearance as well.appearance as well.
normal placenta
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LossLoss ofof the retroplacental hypoechoiczone
Progressive thinningProgressive thinning of theretroplacental hypoechoic zone
Presence of multiple placental lakesmultiple placental lakes("Swiss cheese" appearance)
Thinning of the uterineuterine serosaserosa--bladderbladderwall complexwall complex (percreta)
ElevationElevation of tissue beyond the uterineserosa (percreta)
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Dilated vascular channels with diffuselacunar flow.
Irregular vascular lakes with focallacunar flow.
Hypervascularity linking placenta tobladder.
Dilated vascular channels with pulsatilevenous flow over cervix.
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Newlyformedvessel& multiple
placentallakes
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SensitivitySensitivity SpecificitySpecificity
GRAY SCALEGRAY SCALEUSGUSG9494 7979
COLOURCOLOURDOPPLERDOPPLER
8282 9797
MRIMRI 100100 7272
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CONSERVATIVECONSERVATIVELeave placentaLeave placentaundisturbed +/undisturbed +/--M
ETHOTR
EXATEM
ETHOTR
EXATE
Uterinearteryligation UAE Internaliliacligation Oversewing of placentalbed Condom temponade B-Lynch/squaresutures Argonbeam coagulation
HYSTERECTOMYHYSTERECTOMY
Fertility desired
Patientstable
Nobleeding
Informed writtenconsent
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Intraoperative management
1.-Map exact position of placenta Make hightransverse uterine incision to avoid cutting
through placenta2.- Deliver fetus Rapid hemostasis of uterineincision (clamps, sutures)
TAH
Dguncertain Avoid TAH&Dgcertain
Definitive Rx
UAE/Ligation
Remove pl
Leave Pl in situ
UAE/ligationDo not remove pl
--PlacentaPlacenta AccretaAccreta --
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Pre/intra op EMBOLISATION
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Haemostatic multiplesquaresuture method
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B-LYNCH SUTURES
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Follow-up management
1.- Ultrasound /doppler :Vascularity/involution
2.- HCG titers (If plateau consider Mtx)
3. Daily Temp, Other S&S of infection
4.- Bleeding
5.- Coagulation profile
Oxytocics & prophylactic antibiotics : Benefit& duration not universal
--PlacentaPlacenta AccretaAccreta --
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Follow-up OUTCOME
SPONTANEOUS EXPULSIONRESORPTION
INTERVAL SURGERY placentalremoval
If Intervention necessary for- Heavy Bleeding
- Infection
-D
IC
Proceed directlyto TAH
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Resort tohysterectomy
SOONERRATHERSOONERRATHERTHAN LATERTHAN LATER(especially in cases of
placenta accretawhen future fertilityis out of concern)
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Active Mxofthird stagecanprevent&reducetheincidenceofretained placenta.
Incaseofriskfactors,alwaysconsider placentaaccreta& L/fusg/dopplerfeaturesinantenatal
period & planaccordingly.
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THANK YOUTHANK YOU
32Dr Mona Shroff www.obgyntoday.info