Abnormal placental separation

Question 1

What is abnormal placental separation?

Answer 1

Defective decidual layer of the placenta leading to abnormal attachment and separation during postpartum period

Question 2

What are the risk factors for abnormal placental attachment?

Answer 2

(Prior damage to the endometrium)
History of uterine surgery
Prior births by cesarean section
Placenta previa

Question 3

What are the types of abnormal placental attachment?

Answer 3

(Types based on how much trophoblast penetrate) 
Placenta accreta (80% of cases): chorionic villi attach to the myometrium (but do not invade or penetrate the myometrium) rather than decidua basalis
Placenta increta (15% of cases): chorionic villi invade or penetrate into the myometrium
Placenta percreta (5% of cases): chorionic villi penetrate the through the myometrium, penetrate the serosa, and in some cases, adjacent organs (e.g., rectum or bladder)

Question 4

What are the types of retained placenta?

Answer 4

(Adherent placenta) a placenta that is not detached because of insufficient uterine contractions (uterine atony)
(Trapped placenta) a detached placenta that cannot be delivered spontaneously or with light cord traction because of cervical closure

Question 5

What are the clinical features of abnormal placental separation?

Answer 5

(Retained products of conception) parts of placenta remaining in uterus in post partum period due to abnormal separation
Post-partum haemorrhage
Fever
Tenderness of cervix / pelvis

Question 6

What is the treatment for abnormal placenta separation?

Answer 6

(General measures) Monitoring, adequate large-bore IV access (≥ 16 gauge), and an ice pack
Volume replacement therapy (with intravenous crystalloid solutions)
Oxygenation
(Brandt-Andrews maneuver) One hand is placed on the abdomen, securing the uterine fundus and preventing uterine inversion.
The other hand applies steady downward traction on the umbilical cord.
(Uterotonic agents) Oxytocin: if the placenta remains in the uterus despite traction
Carboprost (Prostaglandin F2-alpha): if the placenta remains in the uterus despite above-mentioned approach
(Last resort) Hysterectomy if continual bleeding