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1. CASE OF MANUAL REMOVAL OF PLACENTA
Presenter : Maj Vaibhaw K
Moderator : Col Suneeta Singh
1
2. PATIENT DETAILS
• 23 yr old
• G2P1L1 @ 38 weeks1 day POG
• With post LSCS status
• Resident of Pune
• Educated till XII , Home maker by choice
• Belongs to lower middle socioeconomic class ( Modified Kuppuswamy Scale)
2
3. HISTORY
• Admitted at 38 weeks 1 days POG
• C/o pain abdomen since 5 hours , intermittent ,gradually increasing
• No c/o bleeding per vaginum
• Perceiving adequate fetal movements
3
4. MENSTRUAL HISTORY
• Menarche: 13yr
• Previous cycles: Regular, 4-5 d/ 30days
• LMP: 01 Sept 2021
• EDD: 08 June 2022
• POG: 38 weeks 1 days
4
6. PRESENT PREGNANCY
1st Trimester:
• Spontaneous conception
• Detected by UPT at Home, confirmed by USG @ 2months
• Booked at civil
• Started on Tab Folic acid 5mg OD
• No h/o fever with rash, bleeding per vaginum, pain abdomen
• No exposure to teratogenic drugs or radiation
• First visit at CHSC ON 20/12/21@12 weeks POG
6
9. PRESENT PREGNANCY
• 2nd Trimester:
• Regular Antenatal visits
• Started on Tab Iron and Tab Calcium
• Immunised with 2 doses of Inj dT
• Quickening felt around 18 weeks period of gestation
• No H/o bleeding / discharge per vaginum in 2nd Trimester
9
11. USG
ANOMALY SCAN (16/02/22)@24 WK 3 DAYS
• SLIUF(+) FCA(+)
• Liquor - Normal
• Placenta –Fundoanterior/NP
• EFW -367gram , USMA -20 WK+2 D
USEDD – 04/007/22
• NO gross anomaly detected at present scan
QUADRUPLE MARKER –LOW RISK
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12. PRESENT PREGNANCY
• 3rd Trimester
• On Regular follow up
• Continued on Tab Iron and Tab Calcium
• No H/o bleeding per vaginum/ pain abdomen
• Uneventful
12
14. PAST HISTORY
NOT a k/c/o
• Type 2 DM
• HTN
• Thyroid disorder
• No h/o any surgery in past
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15. PERSONAL HISTORY
• Mixed diet
• Normal and adequate sleep
• Bowel and bladder habits- Normal
• No addictions
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16. FAMILY HISTORY
• No H/o Hypertension
• Diabetes
• Congenital anomalies in first degree relatives
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17. EXAMINATION
• Average Built & nourished
• Conscious and oriented
• Height: 156 cm, Wt: 63kg kgs, BMI: 25.88 kg/m2
• PR: 84/min Regular, Normal Volume, No R- R delay, No R-F delay
• BP: 112/72 mm Hg – Rt arm, lying position
• No pallor/ icterus/ edema/ cyanosis/ clubbing/ lymphadenopathy
17
18. EXAMINATION
• RS: B/L equal breath sounds, No adventitious sounds
• CVS: S1 & S2 Normal, No diastolic murmurs heard
• CNS: Normal
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19. EXAMINATION
PER ABDOMEN
• Inspection:
• Uniformly distended
• Linea Nigra and Striae gravidarum +
• Umbilicus: Central and everted
• Hernial sites – Normal
• No Scar marks seen
19
21. DIAGNOSIS
• 23 Year old G2P1L1 @ 38 WK 1D POG with post LSCS status with anemia
with longitudinal lie with cephalic presentation in labour willing for
TOLAC
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23. DELIVERY DETAILS
• ARM @0800 Hrs on 22/06/22
• Underwent vacuum assisted VBAC
DOB :22/06/22
TOB : 1014 Hrs
SEX : Male
Birth weight : 2.66 kg
APGAR : 7
:9
23
24. Decision for Manual Removal Of Placenta taken
Piping Gas method applied and failed
Bed side USG done No sign of placental separation seen
Placenta was not expelled even after 30 minutes of delivery of fetus with active
management of third stage of labor
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25. MANUAL REMOVAL OF PLACENTA
• MROP done under GA in OT
• Placenta with membrane delivered in toto
• Episiotomy wound sutured in layers
• Hemostasis ensured
• Total blood loss -500 ml
• Antibiotics prophylaxis given along with supportive treatment
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26. DISCUSSION
Placental separation: uterus undergoes sudden and striking reduction in
size which brings about folding of maternal surface of placenta leads to
placental separation
Method of placental separation:
A)Central separation
B)Marginal separation
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27. PHASES OF 3RD STAGE OF LABOR
Latent phase-Immediately after birth, all of the myometrium
contracts except for the portion beneath the placenta.
Contraction phase-The retroplacental myometrium
contracts.
Detachment phase-Contraction of the retroplacental
myometrium produces horizontal(shear)stress on the
maternal surface of the placenta , causing it to detach.
Expulsion phase-Myometrial contractions expel the
detached placenta from the uterus.
27
28. DEFINITION of RETAINED PLACENTA
Retained placenta can be defined as lack of expulsion of
the placenta within 30 minutes of delivery of the infant.
This definition is suitable in the third trimester when the
third stage of labor is actively managed because 98
percent of placentas are expelled by 30 minutes in this
setting.
Based on the study conducted by Comb et al 1991*
28
29. DEFINITION
In the second trimester and with physiological
management of the third stage , it takes about
60 minutes before 98 percent of placentas are
expelled.
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30. TYPES
• Trapped or incarcerated placenta :separated
placenta but not delivered spontaneously or with
light cord traction because the cervix has begun to
close- failure of the expulsion phase
• Placenta adherens : The placenta is adherent to
uterine wall, but easily separated manually-
contractile failure in the retroplacental area
• Placenta accrete : The placenta is pathologically
invading the myometrium due to defect in the
Decidua-it is a structural rather than a functional
abnormality
30
31. RISK FACTORS
• Preterm , most important risk factor
• Previous history of retained placenta
• Uterine surgery
• Parity >5
• ART procedure
• Stillbirth
• Maternal age >30 years
• Use of ergometrine
• Uterine abnormalities
• Defective placental implantation
• Velamentous cord insertion
Placental insufficiency –infection
,pre-eclampsia
31
32. DIAGNOSIS
A diagnosis of trapped placenta is made when the classic clinical
signs of placental separation are present and the edge of the
placenta is palpable through a narrow cervical OS
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33. DIAGNOSIS
• A diagnosis of placenta adherens or placenta accreta is made in the
absence of signs and symptoms of placental separation
• Ultrasound can differentiate between a detached trapped placenta and
an adherent placenta
• On USG, the myometrium will be thickened in all areas except where
the placenta is attached, where it will be very thin or even invisible
33
34. WHEN TO INTERVENE?
• Retained placenta with post partum haemorrhage is an OBSTETRIC
EMERGENCY.
• For stable 3rd Trimester Deliveries :expectant management can be
continued till 30 minutes
• However , for 2nd trimester deliveries , waiting time can be
extended till 60 min in absence of bleeding
34
35. MANAGEMENT
• CONTROLLED CORD TRACTION
• MANUAL REMOVAL OF PLACENTA
• INSTRUMENT EXTRACTION
• MANAGING UNEXPECTED PLACENTA ACCRETA
• PPH MANAGEMENT
• MANAGING THE UNDERLYING CAUSE
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36. PREREQUSITES
• Ensuring that the mother's bladder is empty
• Offering the baby the breast as it releases
oxytocin causing uterus to contract
• Fundal massage.
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37. MANAGING THE UNDERLYING CAUSE
EXCESSIVE CERVICAL/UTERINE CONTRACTION
If the lower uterus/cervix is contracted , nitroglycerin will result in relaxation
and facilitate placental delivery
• Glyceryl trinitrate two sprays(400 micrograms/spray)
• Sublingual tablets 0.6 to 1.0 milligrams
• IV sequential bolus:50 micrograms, maximum cumulative dose 200
Micrograms, until sufficient uterine relaxation is
achieved
Uterine relaxation occurs within 60 seconds after the dose and lasts1
one to two minutes.
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38. MANAGING THE UNDERLYING CAUSE
ATONY
• IV infusion of oxytocin may facilitate placental delivery
in dose is 10 to 40 units in 500 mL saline
• Prostaglandin F2-alpha may also be of benefit if
bleeding
is severe and not controlled with oxytocin
• Ergometrine should be avoided ,if possible , as it
constricts the cervix , making manual removal very
difficult
39
39. UMBILICAL VEIN OXYTOCIN INJECTION
• WHO support that a dose of 10-20 IU of oxytocin can
be administered Intraumbilically through vein
• It directly reaches the retroplacental myometrium
• Quality of evidence is moderate
40
40. CONTROLLED CORD TRACTION
• Gentle controlled cord traction alone may result in
successful delivery of a trapped or incarcerated
placenta or promote separation of placenta
adherens
• In a Meta analysis of5RCT's in 2013,it was found
that Controlled cord traction appears to reduce
the risk of any postpartum hemorrhage and
manual removal of the placenta
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41. MANUAL REMOVAL OF PLACENTA
MROP is indicated after failed Drug therapy and controlled cord traction
Preparations:
• Consent
• Bladder catheterisation
• Anaesthesia
• IV access
• Routine surgical preparation
• IV Antibiotics
• In cases of excessive uterine contraction , Nitroglycerine is used
42
42. ROLE OF UTERINE CURETTAGE AFTER MROP?
There is no role for routine uterine curettage after manual extraction
However , if placental tissue is retained and the patient is bleeding excessively , then
curettage using a large blunt placental curette is reasonable to remove the remaining
placental tissue
ROLE OROUTINE USG AFTER MROP?
Routine ultrasound for evaluation of the uterus after manual extraction is
also unnecessary.*
43
43. INSTRUMENT EXTRACTION
• If digital extraction is not possible , large-
headed forceps( eg, Bierer forceps)can be used
to grip and extract the placenta in pieces or
intact;
• ultrasound guidance can be helpful.*
• The procedure requires less analgesia than
digital extraction. 44
