Retained placenta and placenta accreta

Question 1

At what point should you suspect a retained placenta?

Answer 1

if ti is not delivered within 30 minutes of the baby in an actively managed 3rd stage and 1 hour in a physiological 3rd stage

Question 2

What are 5 aspects of management of retained placenta?

Answer 2

1. IV access
2. FBC
3. Cross match
4. If it was physiological management, revert to active management (give Syntometrine or oxytocin, try controlled cord traction)
5. If oxytocin not effective within 30 min, transfer to theatre for reginal block and manual removal of placenta

Question 3

What should be given if manual removal of the placenta is required in theatre, along with regional block?

Answer 3

prophylactic antibiotics intraoperatively

Question 4

Why must particular care be taken in the case of a retained placenta?

Answer 4

blood can gather behind the placenta, leading to significant occult blood loss (beware of high uterus full of blood)

Question 5

In what proportion of pregnancies does abnormal placentation occur?

Answer 5

1 in 7000

Question 6

What are three key risk factors for placenta accreta?

Answer 6

1. if there have been prior Caesarean deliveries
2. Other uterine surgery such as myomectomy
3. Repeated surgical termination of pregnancy

Question 7

What happens in abnormal placentation?

Answer 7

• placenta is normally separated from the myometrium by the decidua basalis
• if decidua is abnormal, the villi may invade further through the uterine wall

Question 8

What are the 3 types of abnormal placentation?

Answer 8

1. Placenta accreta: placental villi are attached to the myometrium
2. Placenta increta: villi invaded into >50% of the myometrium
3. Placenta percreta: villi pass through the whole myometrium up to the serosa, potentially involving other viscera (bladder or bowel)

Question 9

What term is often used to refer to all three types of abnormal placentation?

Answer 9

placenta accreta

Question 10

What is the management of placenta accreta post delivery?

Answer 10

• if heavy bleeding,
  
  • blood replacement
  • tamponade with balloon e.g. Rusch
  • hysterectomy
• if minimal bleeding, leaving placenta in situ with close monitoring is an option

Question 11

How is manual removal of the placenta (MROP) performed?

Answer 11

• one hand placed on abdomen to steady uterus (reduce risk of perforation)
• other hand gently inserted through cervix into uterus
• fingers used to identify plane between placenta and uterine wall, and gently separate it
• placenta should be removed in one piece and inspected to ensure it is complete
• uterine cavity is then explored again to make sure it is completely empty

Question 12

What are 4 things that are done at the same time as performing a manual removal of the placenta for a retained plancenta?

Answer 12

1. Oxytocin infusion continued for 4h prophylactically
2. IV antibiotics given
3. Mother observed for bleeding or infection by observing vaginal bleeding, fundal height, change in pulse, BP, temperature, urinary output, and Hb