1. RETAINED PLACENTA
Dr Mona Shroff

2. Definition
Failure of placental delivery within 30 minutes after delivery of the fetus.
Dr Mona Shroff

3. Causes Morbid Adherence of the placenta Uterine Abnormality
Placenta Acreta
Placenta Increta
Placenta Percreta
Uterine Abnormality
Constriction Ring - reforming cervix
Full bladder
Dr Mona Shroff

4. Management Inform Anaesthetist
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)
Dr Mona Shroff

5. Introducing one hand into the vagina along cord
Dr Mona Shroff

6. Supporting the fundus while detaching the placenta 

7. Withdrawing the hand from the uterus

8. POST-PROCEDURE CARE
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.
Dr Mona Shroff

9. Complications of Retained Placenta
Shock
Postpartum haemorrhage
Puerperal Sepsis
Subinvolution 
Hysterectomy  
Dr Mona Shroff

10. Umbilical vein injection for management of retained placenta
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
Dr Mona Shroff

12. largely as a result of the increase in the number of cesarean sections
The incidence of placenta accreta has increased 10-fold in the past 50 years, to a current frequency of 1 per 2,500 deliveries.
largely as a result of the increase in the number of cesarean sections
Dr Mona Shroff

13. Risk factors Risk factors for placenta accreta include :
placenta previa with or without previous uterine surgery.
previous myomectomy.
previous cesarean delivery.
Asherman's syndrome.
submucous leiomyomata.
maternal age of 36 years and older.
The ACOG committee
Dr Mona Shroff

14. Prenatal risk probability
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 placenta previa & previous CS.
Dr Mona Shroff

15. Gray-scale sonographic signs of placenta accreta
normal placenta
characterized by a hypoechoic boundary between the placenta and the urinary bladder that represents the myometrium and normal retroplacental myometrial vasculature. The normal placenta has a homogenous appearance as well.
Dr Mona Shroff

17. Gray-scale sonographic signs of placenta accreta
Loss of the retroplacental hypoechoic zone
Progressive thinning of the retroplacental hypoechoic zone
Presence of multiple placental lakes ("Swiss cheese" appearance)
Thinning of the uterine serosa-bladder wall complex (percreta)
Elevation of tissue beyond the uterine serosa (percreta)
Dr Mona Shroff

18. Color Doppler signs suggestive of placenta accreta
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.
Dr Mona Shroff

19. Multiple layers of newly formed vessel
Newly formed vessel & multiple placental lakes
Dr Mona Shroff

20. Sensitivity Specificity GRAY SCALE USG 94 79 COLOUR DOPPLER 82 97 MRI
100 72
Dr Mona Shroff

21. MANAGEMENT HYSTERECTOMY CONSERVATIVE
Leave placenta undisturbed +/- METHOTREXATE
Uterine artery ligation
UAE
Internal iliac ligation
Oversewing of placental bed
Condom temponade
B-Lynch/square sutures
Argon beam coagulation
Fertility desired
Patient stable
No bleeding
Informed written consent
Dr Mona Shroff

22. -Placenta Accreta - 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)
Definitive Rx
Dg uncertain
Avoid TAH & Dg certain
Do not remove pl
UAE/Ligation
UAE/ligation
TAH
Remove pl
Leave Pl in situ
Dr Mona Shroff

24. Pre/intra op EMBOLISATION

25. Haemostatic multiple square suture method

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

28. -Placenta Accreta - 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
Dr Mona Shroff

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

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

31. Take home message
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.
Dr Mona Shroff

32. THANK YOU
Dr Mona Shroff