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Andrew Weeks - One of the best experts on this subject based on the ideXlab platform.
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Retained Placenta: will medical treatment ever be possible?
Acta Obstetricia et Gynecologica Scandinavica, 2016Co-Authors: Achier D. Akol, Andrew WeeksAbstract:The standard treatment for Retained Placenta is manual removal whatever its subtype (adherens, trapped or partial accreta). Although medical treatment should reduce the risk of anesthetic and surgical complications, they have not been found to be effective. This may be due to the contrasting uterotonic needs of the different underlying pathologies. In Placenta adherens, oxytocics have been used to contract the retro-Placental myometrium. However, if injected locally through the umbilical vein, they bypass the myometrium and perfuse directly into the venous system. Intravenous injection is an alternative but exacerbates a trapped Placenta. Conversely, for trapped Placentas, a relaxant could help by resolving cervical constriction, but would worsen the situation for Placenta adherens. This confusion over medical treatment will continue unless we can find a way to diagnose the underlying pathology. This will allow us to stop treating the Retained Placenta as a single entity and to deliver targeted treatments.
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The Retained Placenta: historical and geographical rate variations.
Journal of Obstetrics and Gynaecology, 2011Co-Authors: W. M. C. Cheung, A. Hawkes, S. Ibish, Andrew WeeksAbstract:In this study, we sought to explore the variation in reported rates of Retained Placenta around the world and over time in the UK. A systematic review of observational studies was performed to obtain Retained Placenta rates from around the world and annual hospital reports from the Royal College of Obstetricians and Gynaecologists archives were examined to obtain historical Retained Placenta rates. The data show that the median rate of Retained Placenta at 30 minutes was higher in developed countries (2.67% vs 1.46%, p
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the Retained Placenta historical and geographical rate variations
Journal of Obstetrics and Gynaecology, 2011Co-Authors: W. M. C. Cheung, A. Hawkes, S. Ibish, Andrew WeeksAbstract:In this study, we sought to explore the variation in reported rates of Retained Placenta around the world and over time in the UK. A systematic review of observational studies was performed to obtain Retained Placenta rates from around the world and annual hospital reports from the Royal College of Obstetricians and Gynaecologists archives were examined to obtain historical Retained Placenta rates. The data show that the median rate of Retained Placenta at 30 minutes was higher in developed countries (2.67% vs 1.46%, p < 0.02), as was the median manual removal rate (2.24% vs 0.45%, p < 0.001). In addition to this, there appears to have been a rise in rate of manual removal in the UK from a mean of 0.66% in the 1920s to 2.34% in the 1980s (p < 0.0001).
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The Retained Placenta.
Best Practice & Research in Clinical Obstetrics & Gynaecology, 2008Co-Authors: Andrew WeeksAbstract:The incidence and importance of Retained Placenta (RP) varies greatly around the world. In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate. In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely associated with mortality. There are three main types of Retained Placenta following the vagina delivery: Placenta adherens (when there is failed contraction of the myometrium behind the Placenta), trapped Placenta (a detached Placenta trapped behind a closed cervix) and partial accreta (when there is a small area of accreta preventing detachment). All can be treated by manual removal of Placenta, which should be carried out at 30-60 minutes postpartum. Medical management is also an option for Placenta adherens and trapped Placenta. The need for manual removal can be reduced by 20% by the use of intraumbilical oxytocin (30 i.u. in 30 mL saline). A trapped Placenta may respond to glyceryl trinitrate (500 mcg sublingually) or gentle, persistent, controlled cord traction.
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The Retained Placenta.
African Health Sciences, 2001Co-Authors: Andrew WeeksAbstract:The Retained Placenta is a significant cause of maternal mortality and morbidity throughout the developing world. It complicates 2% of all deliveries and has a case mortality rate of nearly 10% in rural areas. Ultrasound studies have provided fresh insights into the mechanism of the third stage of labour and the aetiology of the Retained Placenta. Following delivery of the baby, the retro-Placental myometrium is initially relaxed. It is only when it contracts that the Placenta shears away from the Placental bed and is detached. This leads to its spontaneous expulsion. Retained Placenta occurs when the retro-Placental myometrium fails to contract. There is evidence that this may also occur during labour leading to dysfunctional labour. It is likely that this is caused by the persistence of one of the Placental inhibitory factors that are normally reduced prior to the onset of labour, possibly progesterone or nitric oxide. Presently, the only effective treatment is manual removal of Placenta (MROP) under anaesthetic. This needs to be carried out within a few hours of delivery to avoid haemorrhage. For women in rural Africa, facilities for MROP are scarce, leading to high mortality rates. Injection of oxytocin into the umbilical vein has been suggested as an alternative. This method relies on the injected oxytocin passing through the Placenta to contract the retro-Placental myometrium and cause its detachment. Despite several placebo controlled trials of this technique, no firm conclusion have been reached regarding its efficacy. This may be due to inadequate delivery of the oxytocin to the Placenta. Further trials are in progress to assess the optimal dose of oxytocin as well as the efficacy of a new technique designed to improve delivery of the oxytocin to the Placental bed.
Usha Verma - One of the best experts on this subject based on the ideXlab platform.
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rectal misoprostol vs 15 methyl prostaglandin f2α for Retained Placenta after second trimester delivery
American Journal of Obstetrics and Gynecology, 2009Co-Authors: Subha Sundaram, John P Diaz, Victor Hugo Gonzalezquintero, Usha VermaAbstract:Objective The purpose of this study was to compare rectal misoprostol (RM) with 15-methyl prostaglandin F2α (PGF 2α ) for the management of Retained Placenta after second-trimester deliveries. Study Design A retrospective study of all second-trimester deliveries between the years 2000 and 2005 was performed. Women were divided into 2 groups, depending on whether they received RM or PGF 2α after the delivery. Results Three hundred three second-trimester deliveries were analyzed. The time from the administration of medications to the Placental delivery was significantly shorter in women who received PGF 2α , compared with the RM group (49.5 vs 89 minutes; P 2α had lower rates of Retained Placenta (4.9% vs 12.4%; P = .02). Conclusion The use of PGF 2α after second-trimester deliveries results in shorter third stage of labor and lower rates of Retained Placenta compared with RM.
Subha Sundaram - One of the best experts on this subject based on the ideXlab platform.
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rectal misoprostol vs 15 methyl prostaglandin f2α for Retained Placenta after second trimester delivery
American Journal of Obstetrics and Gynecology, 2009Co-Authors: Subha Sundaram, John P Diaz, Victor Hugo Gonzalezquintero, Usha VermaAbstract:Objective The purpose of this study was to compare rectal misoprostol (RM) with 15-methyl prostaglandin F2α (PGF 2α ) for the management of Retained Placenta after second-trimester deliveries. Study Design A retrospective study of all second-trimester deliveries between the years 2000 and 2005 was performed. Women were divided into 2 groups, depending on whether they received RM or PGF 2α after the delivery. Results Three hundred three second-trimester deliveries were analyzed. The time from the administration of medications to the Placental delivery was significantly shorter in women who received PGF 2α , compared with the RM group (49.5 vs 89 minutes; P 2α had lower rates of Retained Placenta (4.9% vs 12.4%; P = .02). Conclusion The use of PGF 2α after second-trimester deliveries results in shorter third stage of labor and lower rates of Retained Placenta compared with RM.
Omar M Shaaban - One of the best experts on this subject based on the ideXlab platform.
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nitroglycerin for management of Retained Placenta
Cochrane Database of Systematic Reviews, 2015Co-Authors: Hany Abdelaleem, Mahmoud A Abdelaleem, Omar M ShaabanAbstract:Background Retained Placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of nitroglycerin (NTG), either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the Placenta in theatre under anaesthesia. Objectives To evaluate the benefits and harms of NTG as a tocolytic, either alone or in addition to uterotonics, in the management of Retained Placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (14 January 2015), reference lists of retrieved studies and contacted experts in the field. Selection criteria Any adequately randomised controlled trial (RCT) comparing the use of NTG, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of Retained Placenta. All women having a vaginal delivery with a Retained Placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the Placenta was not delivered at least within 15 minutes after delivery of the baby. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We included three randomised controlled trials (RCTs) with 175 women. The three published RCTs compared NTG alone versus placebo. The detachment status of Retained Placenta was unknown in all three RCTs. Collectively, among the three included trials, two were judged to be at low risk of bias and the third trial was judged to be at high risk of bias for two domains: incomplete outcome data and selective reporting. The three trials reported seven out of 23 of the review's pre-specified outcomes. The primary outcome "manual removal of the Placenta" was reported in all three studies. No differences were seen between NTG and placebo for manual removal of the Placenta (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.47 to 1.46; women = 175; I² = 81%). A random-effects model was used because of evidence of substantial heterogeneity in the analysis. There were also no differences between groups for risk of severe postpartum haemorrhage (RR 0.93, 95% CI 0.62 to 1.39; women = 150; studies = two; I² = 0%). Blood transfusion was only reported in one study (40 women) and again there was no difference between groups (RR 1.00, 95% CI 0.07 to 14.90; women = 40; I² = 0%). Mean blood loss (mL) was reported in the three studies and no differences were observed (mean difference (MD) -115.31, 95% CI -306.25 to 75.63; women = 169; I² = 83%). Nitroglycerin administration was not associated with an increase in headaches (RR 1.09, 95% CI 0.80 to 1.47; women = 174; studies = three; I² = 0%). However, nitroglycerin administration was associated with a significant, though mild, decrease in systolic and diastolic blood pressure and a significant increase in pulse rate (MD -3.75, 95% CI -7.47 to -0.03) for systolic blood pressure, and (MD 6.00, 95% CI 3.07 to 8.93) for pulse rate (beats per minute) respectively (reported by only one study including 24 participants). Maternal mortality and addition of therapeutic uterotonics were not reported in any study. Authors' conclusions In cases of Retained Placenta, currently available data showed that the use of NTG alone did not reduce the need for manual removal of Placenta. This intervention did not increase the incidence of severe postpartum haemorrhage nor the need for blood transfusion. Haemodynamically, NTG had a significant though mild effect on both pulse rate and blood pressure.
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The Cochrane Library - Nitroglycerin for management of Retained Placenta.
Cochrane Database of Systematic Reviews, 2015Co-Authors: Hany Abdel-aleem, Mahmoud A. Abdel-aleem, Omar M ShaabanAbstract:Background Retained Placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of nitroglycerin (NTG), either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the Placenta in theatre under anaesthesia. Objectives To evaluate the benefits and harms of NTG as a tocolytic, either alone or in addition to uterotonics, in the management of Retained Placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (14 January 2015), reference lists of retrieved studies and contacted experts in the field. Selection criteria Any adequately randomised controlled trial (RCT) comparing the use of NTG, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of Retained Placenta. All women having a vaginal delivery with a Retained Placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the Placenta was not delivered at least within 15 minutes after delivery of the baby. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We included three randomised controlled trials (RCTs) with 175 women. The three published RCTs compared NTG alone versus placebo. The detachment status of Retained Placenta was unknown in all three RCTs. Collectively, among the three included trials, two were judged to be at low risk of bias and the third trial was judged to be at high risk of bias for two domains: incomplete outcome data and selective reporting. The three trials reported seven out of 23 of the review's pre-specified outcomes. The primary outcome "manual removal of the Placenta" was reported in all three studies. No differences were seen between NTG and placebo for manual removal of the Placenta (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.47 to 1.46; women = 175; I² = 81%). A random-effects model was used because of evidence of substantial heterogeneity in the analysis. There were also no differences between groups for risk of severe postpartum haemorrhage (RR 0.93, 95% CI 0.62 to 1.39; women = 150; studies = two; I² = 0%). Blood transfusion was only reported in one study (40 women) and again there was no difference between groups (RR 1.00, 95% CI 0.07 to 14.90; women = 40; I² = 0%). Mean blood loss (mL) was reported in the three studies and no differences were observed (mean difference (MD) -115.31, 95% CI -306.25 to 75.63; women = 169; I² = 83%). Nitroglycerin administration was not associated with an increase in headaches (RR 1.09, 95% CI 0.80 to 1.47; women = 174; studies = three; I² = 0%). However, nitroglycerin administration was associated with a significant, though mild, decrease in systolic and diastolic blood pressure and a significant increase in pulse rate (MD -3.75, 95% CI -7.47 to -0.03) for systolic blood pressure, and (MD 6.00, 95% CI 3.07 to 8.93) for pulse rate (beats per minute) respectively (reported by only one study including 24 participants). Maternal mortality and addition of therapeutic uterotonics were not reported in any study. Authors' conclusions In cases of Retained Placenta, currently available data showed that the use of NTG alone did not reduce the need for manual removal of Placenta. This intervention did not increase the incidence of severe postpartum haemorrhage nor the need for blood transfusion. Haemodynamically, NTG had a significant though mild effect on both pulse rate and blood pressure.
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tocolysis for management of Retained Placenta
Cochrane Database of Systematic Reviews, 2011Co-Authors: Hany Abdelaleem, Mahmoud A Abdelaleem, Omar M ShaabanAbstract:Background Retained Placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of tocolytics, either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the Placenta in theatre under anaesthesia. Objectives Evaluate the benefits and harms of tocolytics alone or in addition to uterotonics in the management of Retained Placenta in order to reduce the need for manual removal of Placenta. Search strategy We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2010) and contacted experts in the field. Selection criteria Any adequately randomised controlled trial (RCT) comparing the use of tocolytics, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of Retained Placenta. All women having a vaginal delivery with a Retained Placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the Placenta was not delivered at least within 15 minutes after delivery of the baby. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Consultation of the third author was done if needed. Main results We included one RCT (involving 24 women). It compared the use of nitroglycerin tablets versus placebo after the treatment with oxytocin failed. There was a statistically significant reduction in the need for manual removal of Placenta (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.66). There was also a statistically significant reduction in mean blood loss during the third stage of labour (mean difference (MD) -262.50 ml, 95% CI -364.95 to -160.05). Sublingual nitroglycerin caused some haemodynamic changes as it lowers the systolic blood pressure and diastolic blood pressure by a means of 6 and 5 mmHg respectively. Pulse rate increased by a mean of two beats per minute. Authors' conclusions Sublingual nitroglycerin, given when oxytocin fails, seems to reduce both the need for manual removal of Placenta and blood loss during the third stage of labour when compared to placebo. Further trials are needed to confirm its clinical role and safety. Its routine use cannot be recommended based on a single small study. There is no evidence available for other types of tocolytics.
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The Cochrane Library - Tocolysis for management of Retained Placenta.
Cochrane Database of Systematic Reviews, 2011Co-Authors: Hany Abdel-aleem, Mahmoud A. Abdel-aleem, Omar M ShaabanAbstract:Background Retained Placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of tocolytics, either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the Placenta in theatre under anaesthesia. Objectives Evaluate the benefits and harms of tocolytics alone or in addition to uterotonics in the management of Retained Placenta in order to reduce the need for manual removal of Placenta. Search strategy We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2010) and contacted experts in the field. Selection criteria Any adequately randomised controlled trial (RCT) comparing the use of tocolytics, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of Retained Placenta. All women having a vaginal delivery with a Retained Placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the Placenta was not delivered at least within 15 minutes after delivery of the baby. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Consultation of the third author was done if needed. Main results We included one RCT (involving 24 women). It compared the use of nitroglycerin tablets versus placebo after the treatment with oxytocin failed. There was a statistically significant reduction in the need for manual removal of Placenta (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.66). There was also a statistically significant reduction in mean blood loss during the third stage of labour (mean difference (MD) -262.50 ml, 95% CI -364.95 to -160.05). Sublingual nitroglycerin caused some haemodynamic changes as it lowers the systolic blood pressure and diastolic blood pressure by a means of 6 and 5 mmHg respectively. Pulse rate increased by a mean of two beats per minute. Authors' conclusions Sublingual nitroglycerin, given when oxytocin fails, seems to reduce both the need for manual removal of Placenta and blood loss during the third stage of labour when compared to placebo. Further trials are needed to confirm its clinical role and safety. Its routine use cannot be recommended based on a single small study. There is no evidence available for other types of tocolytics.
Yuji Itai - One of the best experts on this subject based on the ideXlab platform.
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Postpartum MR diagnosis of Retained Placenta accreta
European Radiology, 2004Co-Authors: Yumiko Oishi Tanaka, Sadahiko Shigemitsu, Yoshihito Ichikawa, Satoshi Sohda, Hiroyuki Yoshikawa, Yuji ItaiAbstract:Retained Placenta accreta can cause catastrophic postpartum hemorrhage. This study aims to determine whether MR imaging can differentiate Retained Placenta accreta from postpartum hemorrhage caused by other conditions. Fourteen cases suspicious for Retained Placenta were examined with MR imaging. Signal intensity, the enhancing pattern of uterine contents, and flow voids within the myometrium were retrospectively studied. As hysterectomy was performed in only two cases, final diagnosis was based on clinical outcome and analysis of uterine contents. Final diagnoses were Retained Placenta accreta in seven cases, Retained normally attached Placenta in four, hematoma in two, and Placental site trophoblastic tumor (PSTT) in one. All seven cases with Placenta accreta had a very hyperintense area on T2-weighted images, showing transient early enhancement. None demonstrated delayed strong enhancement around the hyperintense area. In two cases with Retained normally attached Placenta and in both with hematomas, there were no hyperintense areas on T2-weighted images. Of these, only one showed transient early enhancement. Flow voids were observed in four cases with Placenta accreta, one with normally attached Placenta, and the case with PSTT. A markedly hyperintense area on T2-weighted images and transient early enhancement without delayed strong enhancement between the mass and the myometrium can indicate Retained Placenta accreta.
