Presented by: Ahmad mukhtar MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of MEDICINE, Zagazig University.

1. Dr- Ahmed mukhtar
RETAINED
PLACENTA
1

2.  Failure of placental delivery
within 30 minutes after
delivery of the fetus.
2

3.  Morbid Adherence of the placenta
Placenta Acreta
Placenta Increta
Placenta Percreta
 Uterine Abnormality
 Constriction Ring - reforming cervix
 Full bladder

4. If the placenta is undelivered after 30 minutes consider:
 Emptying bladder
 Breastfeeding or nipple stimulation
 Change of position - encourage an upright position
If bleeding: immediately
 Inform Anaesthetist
 Insertion of large bore IV (18g) cannula
 Insert urinary catheter
 Commence/continue oxytocin infusion 20 units in 1
litre / rate – 60drops per min
 Measure and accurately record blood loss
 Prepare and transfer patient to theatre for manual
removal of placenta (MROP)
4

5. • Introducing one hand into
the vagina along cord
5

6. Supporting the fundus while
detaching the placenta
6

7. Withdrawing
the hand from
the uterus
7

8.  Observe the woman closely until the
effect of IV sedation has worn off.
 Monitor the vital signs (pulse, blood
pressure, respiration) every 30 minutes
for the next 6 hours or until stable.
 Palpate the uterine fundus to ensure
that the uterus remains contracted.
 Check for excessive lochia.
 Continue infusion of IV fluids.
 Transfuse as necessary.
8

9.  Shock
 Postpartum haemorrhage
 Puerperal Sepsis
 Subinvolution
 Hysterectomy
9

10.  Umbilical vein injection of saline solution
plus oxytocin appears to be effective in
the management of retained placenta.
Saline solution alone does not appear be
more effective than expectant
management. The difficulties in
implementing this intervention are related
to the training of personnel in the
technique of giving injections into the
umbilical vein.The WHO Reproductive Health Library, No 8, Oxford, 2005.
The Cochrane Database of Systematic Reviews 2006 Issue 4
10

11. 11

12. The incidence of placenta accreta
has increased 10-fold10-fold in thein the
past 50 yearspast 50 years, to a current
frequency of 1 per 2,5001 per 2,500
deliveriesdeliveries.
largely as a result of the
increase in the number ofincrease in the number of
cesarean sectionscesarean sections

13. 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

14. Because of the fact that many of these
cases become evident only at the first
attempt to separate the placenta at
delivery, it is essential to attempt to
identify antenatally both placenta accreta
and its attendant risk factors, the most
common of which is concurrent placentaconcurrent placenta
previa & previous CS.previa & previous CS.

15. characterized bycharacterized by a hypoechoic boundarya hypoechoic boundary
between the placenta and the urinarybetween the placenta and the urinary
bladder that represents the myometriumbladder that represents the myometrium
and normal retroplacental myometrialand normal retroplacental myometrial
vasculature.vasculature.
The normal placenta has a homogenousThe normal placenta has a homogenous
appearance as well.appearance as well.
normal placenta

16. 16

17.  LossLoss ofof the retroplacental hypoechoic
zone
 Progressive thinningProgressive thinning of the
retroplacental hypoechoic zone
 Presence of multiple placental lakesmultiple placental lakes
("Swiss cheese" appearance)
 Thinning of the uterine serosa-bladderuterine serosa-bladder
wall complexwall complex (percreta)
 ElevationElevation of tissue beyond the uterine
serosa (percreta)

18.  Dilated vascular channels with diffuse
lacunar flow.
 Irregular vascular lakes with focal
lacunar flow.
 Hypervascularity linking placenta to
bladder.
 Dilated vascular channels with pulsatile
venous flow over cervix.

19. Newly formed
vessel & multiple
placental lakes

20. SensitivitySensitivity SpecificitySpecificity
GRAY SCALEGRAY SCALE
USGUSG
9494 7979
COLOURCOLOUR
DOPPLERDOPPLER
8282 9797
MRIMRI 100100 7272

21. CONSERVATIVECONSERVATIVE
Leave placentaLeave placenta
undisturbed +/-undisturbed +/-
METHOTREXATEMETHOTREXATE
 Uterine artery ligation
 UAE
 Internal iliac ligation
 Oversewing of placental bed
 Condom temponade
 B-Lynch/square sutures
 Argon beam coagulation
HYSTERECTOMYHYSTERECTOMY
Fertility desired
Patient stable
No bleeding
Informed written consent

22. Intraoperative management
1.-Map exact position of placenta  Make high
transverse uterine incision to avoid cutting
through placenta
2.- Deliver fetus  Rapid hemostasis of uterine
incision (clamps, sutures)
TAH
Dg uncertain Avoid TAH &
Dg certain
Definitive Rx
UAE/Ligation
Remove pl
Leave Pl in situ
UAE/ligation
Do not remove pl
--Placenta AccretaPlacenta Accreta --
22

24. Pre/intra op EMBOLISATION
24

25. Haemostatic multiple square
suture method

26. 26

27. 1
2
3
4
5
6
B-LYNCH SUTURES
27

28. 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
--Placenta AccretaPlacenta Accreta --

29. Follow-up OUTCOME
•SPONTANEOUS EXPULSION
•RESORPTION
•INTERVAL SURGERY –placental removal
If Intervention necessary for
- Heavy Bleeding
- Infection
- DIC
Proceed directly to TAH

30. Resort to hysterectomy
SOONER RATHERSOONER RATHER
THAN LATERTHAN LATER
(especially in cases of
placenta accreta when
future fertility is out
of concern)

31.  Active Mx of third stage can
prevent & reduce the incidence of
retained placenta.
 In case of risk factors,always
consider placenta accreta & L/f
usg/doppler features in antenatal
period & plan accordingly.
31Dr Mona Shroff www.obgyntoday.info

32. Thank youThank you