Ret placenta
- 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
- 25. Haemostatic multiple square suture method
- 26. 26
- 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