The retained placenta-new insights into an old problem.
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Female↗
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Conservative treatment of placenta accreta.
Prolonged retained placenta causing a delayed postpartum hemorrhage is a relatively common occurrence. However, there is a dearth of medical literature describing fertility-preserving treatments when standard therapy fails. We present two cases in which protracted retained placenta due to placenta accreta was successfully treated by hysteroscopic resection. Two nulliparous women had spontaneous vaginal deliveries requiring manual placental extraction. Both experienced delayed postpartum hemorrhage and underwent suction curettage with ultrasound guidance. Both patients were found to have persistent products of conception with imaging consistent with placenta accreta. Both patients failed expectant management and subsequently underwent hysteroscopic resection with complete resolution of their symptoms. We conclude that hysteroscopic resection is a conservative therapeutic option for placenta accreta in stable patients.
Adult↗
The equine endometrial mast cell during the puerperal period: evaluation of mast cell numbers and types in comparison to other inflammatory changes.
Endometrial biopsies of 44 broodmares were histologically examined on days 3, 6, and 9 postpartum. The mares were subdivided into three groups according to the course of the puerperal period. In 29 mares, parturition and expulsion of the placenta was normal, six mares showed dystocia, and in nine mares, the placenta was retained for > 2 hours. Tissue samples were evaluated histologically, and the average numbers of granulocytes, lymphocytes, macrophages, siderophages, and mast cells was determined. Protease content of mast cells was examined with a double-enzyme immunohistochemical staining technique, using a histochemical reaction for chloroacetate esterase and fast blue to detect chymase activity and an immunohistochemical staining method with a polyclonal antibody and fast red for the detection of tryptase. Analyzing the cell numbers using the statistical software Statistica, a marked inflammatory reaction was observed in the endometrium postpartum. Although the number of granulocytes decreased during the first 9 days postpartum, the number of lymphocytes, macrophages, and siderophages increased. No significant difference in the number of any of these cell types could be demonstrated in the three different courses of the puerperal period, although the numbers of these cells seemed to be lower in mares with dystocia. In contrast with other cells, no change in the number of endometrial mast cells was observed during the puerperal period, but a significantly lower number were found in the endometrium of mares with retained placenta. The enzyme immunohistochemical double-labeling technique could demonstrate only tryptase-positive mast cells; no chymase activity was detectable in any endometrial mast cells. The number of mast cells detected with the metachromatic staining technique was significantly higher than that detected with double labeling. These results support the hypothesis that a sufficient number of mast cells may be necessary for a normal postnatal period and suggest a mast cell subtype in the equine endometrium that is tryptase and chymase negative.
Animals↗
Interrelationships between production and reproductive diseases in Holstein cows. Conditional relationships between production and disease.
By methods of conditional odds ratio with a set of 2960 Holstein lactation records, relationships between occurrences of disease in a lactation were examined. There were strong positive relationships between retained placenta and metritis and between cystic follicle and luteal cyst. Interaction was among dystocia, retained placenta, and metritis and among retained placenta, cystic follicle, and luteal cyst. Metritis was an intervening variable between retained placenta and cystic follicle, retained placenta was a common cause variable for metritis and luteal cyst, and cystic follicle was either an intervening variable or a common cause for metritis and luteal cyst. Discriminant analyses were used to investigate production variables and other diseases as causes of disease, and multiple regression analyses indicated effects of disease on other diseases and current production in a subset of 810 lactation records. Breed class averages for milk and fat, days in milk, and dry period in one lactation had little effect on occurrence of disease in the subsequent lactation. Metritis, cystic follicle, and luteal cyst directly increased calving interval 20 to 27 days. Cystic follicle directly increased breed class averages 5.5 points. None of the five diseases directly increased days in milk.
Animals↗
Trends in maternal mortality due to haemorrhage: two decades of Indian rural observations.
Obstetric haemorrhage continues to be a major cause of maternal mortality. Our analysis of records of over a period of 20 years from April 1982 to March 2002 reveals that it was a contributory cause of maternal mortality in 19.9% of cases. The majority of deaths, (65%) had occurred within 24 hours of admission and in 47.5% of cases there was severe anaemia on admission; 17.5% had died due to an atonic PPH, which was the largest category, followed by ruptured uterus (15%), abruptio placenta (15%) and retained placenta (12.5%). Deaths due to obstetric haemorrhage because of a ruptured uterus, retained placenta and abortion have decreased from 22.22% between 1982 and 1987 to zero in the last 5 years and an increase was seen in deaths due to haemorrhage because of gestational trophoblastic neoplasia and ectopic pregnancy, from 1.69% to 4.87%, unclassified haemorrhage 1.96% to 7.31% and placenta praevia from zero between 1982 and 1987 to 4.87% between 1997 and 2002.
Adolescent↗
Changes in the serum levels of human chorionic gonadotropin and the pulsatility index of uterine arteries during conservative management of retained adherent placenta.
OBJECTIVE: Our purpose was to assess the natural course of retained adherent placenta at term. METHODS: Five cases of retained adherent placenta, clinically diagnosed as placenta accreta, were managed conservatively without methotrexate. To assess the biochemical and circulatory changes in the placentas, the serum levels of human chorionic gonadotropin (hCG) and the pulsatility index (PI) of the uterine arteries were examined. RESULTS: Serum hCG levels decreased spontaneously; the half-life of serum hCG was calculated to be 5.2 +/- 0.26 days (mean +/- SEM). The PI of the uterine arteries remained at the level of pregnant women at term, but became elevated within a few days after the removal of the placentas. All the placentas were successfully removed transvaginally within 6 weeks postpartum. CONCLUSIONS: The changes in serum hCG observed in this study indicated the spontaneous degeneration of the placenta. Such changes might be similar to those reported to occur during treatment with methotrexate. In contrast, the PI of the uterine arteries did not reflect degeneration of the placenta.
Adult↗
[Changes in blood levels of progesterone, triiodothyronine and thyroxine and the results of quantitative histological analysis of the placentoma and corpus luteum in cows after prolonged labor].
Changes in the cell structure of the placentoma and the corpus luteum were subjected to quantitative histological investigation, parallel with the examination of the concentrations of progesterone (P4), triiodotyronine (T3) and tyroxin (T4) during parturition (Oth hour) and two and six hours after parturition. The hormone concentrations were determined by the RIA method. The results of the quantitative histological analysis of the placentomae and the corpus luteum suggest that when the placenta is retained there is a significantly higher number of maintained epithelial cells in the placentoma crypts and a higher number of unchanged small, dark and large, light lutein serraetion cells in the biopsy of the corpus luteum during the period under investigation. The morphological finding significantly correlates with higher concentrations of P4 in the blood of the cows with retained placenta, as compared with those whose placenta was not retained. It can be derived from the pattern of changes in T3 and T4 concentrations, compared with P4 and with the histological finding, that there is a functional relationship between the placentoma, corpus luteum, and the thyroid gland.
Animals↗
Induced abortion and placenta complications in the subsequent pregnancy.
BACKGROUND: To study the risk of placenta complications following an induced abortion as a function of the interpregnancy interval. METHODS: This study is based on three Danish national registries; the Medical Birth Registry, the Hospital Discharge Registry, and the Induced Abortion Registry. All primigravida women from 1980 to 1982 were identified in these three registries. A total of 15,727 women who terminated the pregnancy with a first trimester induced abortion were selected to the abortion cohort, and 46,026 women who did not terminate the pregnancy with an induced abortion constituted the control cohort. By register linkage all subsequent pregnancies were identified from 1980 to 1994. Only women who had a non-terminated pregnancy following the index pregnancy were selected to the study. Placenta complications were identified using either the Hospital Discharge Registry ICD-8 codes or the Medical Birth Registry records. RESULTS: A slightly higher risk of placenta complications following an abortion was found. Retained placenta occurred more frequently in women with one, two or more previous abortions, compared with women without any previous abortion of similar gravidity. Adjusting for maternal age and residence at time of pregnancy, the interpregnancy interval, and the number of previous miscarriages (control cohort only), the odds ratios of retained placenta in deliveries of singleton live births in women with one previous abortion was 1.17 (95%CI=1.02-1.35), and for women with two or more previous abortions it was 1.68 (95%CI=1.23-2.30), respectively, compared with the control cohort of similar gravidity. Only for women who had one abortion did the results follow the predicted pattern of a higher risk of retained placenta after a short pregnancy interval. No association with placenta previa was seen. CONCLUSIONS: The findings suggest a positive association between abortions and retained placenta in subsequent singleton live births, but the association was weak and confounding cannot be ruled out.
Abortion, Induced↗
Genetic interrelationships of parturition problems and production.
Data were 5091 calvings from 3904 cows for milk fever, retained placenta, mastitis within 48-h postpartum, calving difficulty, and 48-h calf livability collected from 27 large California dairies analyzed for genetic interrelationships among parturition problems. Heritability of each trait was small; however, retained placenta had large positive genetic correlations with milk fever (.34) and mastitis (.33). Adding difficulty-mortality classes to models to study genetic relationships of parturition problems had little effect on estimates but did influence incidence of parturition problems. With calving difficulty, incidence of milk fever increased by 4.9% and retained placenta by 5.3%. With calf mortality, milk fever increased by 4.4% and retained placenta by 13%. A combination of difficulty and mortality was related to a 9.6% increase of milk fever and a 20.2% increase of retained placenta. Genetic correlations of all problems with mature equivalent milk indicated that selection for increased production would be accompanied by lower incidence of retained placenta, 48-h mastitis, and milk fever. Genetic correlations of retained placenta with milk fever and 48-h mastitis were positive. Selection for increased milk yield should not increase incidence of parturition problems, and prescreening of bulls on parturition performance of daughters would be feasible.
Animals↗
Immunohistological examination on the distribution of collagen types I, III, IV and V in bovine post partum placentomes.
This paper describes the in situ presence and distribution of collagen types I, III, IV and V in the bovine placenta. The objective was to determine whether there are qualitative and/or quantitative differences in the collagen content of placentomes originating from cows with retained placenta and cows with normal discharge of placenta. Twelve h post partum discharge of the placenta or the incidence of retained placenta was monitored. From 57 cows one placentome per cow was collected within 1 h post partum. The cows were divided into three groups: retained placenta after caesarean section (Group 1), retained placenta after spontaneous calving (Group 2) and normal discharge of placenta within 12 h post partum after spontaneous calving (Group 3). A pilot study was conducted to establish the technique of collecting the placentomes and to verify the applied immunohistological methods used in this work. In the following study, 32 placentomes were used to determine the amount of collagen (types I, III, IV and V) with qualitative and semi-quantitative methods using immunohistochemical techniques. Collagen types I, III, IV and V were found in large quantities in the maternal tissue. In the fetal connective tissue the amount of these collagen types was smaller. In the placentomes of the three groups, no qualitative or quantitative differences could be detected.
Animals↗
Risk factors for placenta praevia in southern Nigeria.
OBJECTIVE: To determine the risk factors for placenta praevia in Ile-Ife, southern Nigeria. DESIGN: A prospective case control study. SETTING: A tertiary center--Obafemi Awolowo University Teaching Hospital, Ile-Ife, southern Nigeria. SUBJECTS: One hundred and thirty six patients with confirmed placenta praevia constituted the cases. Controls consisted of one hundred and thirty six patients who delivered at term immediately after each indexed case and did not have placenta praevia. RESULTS: Cases and controls were similar in terms of twin deliveries (P = 0.72) and past history of uterine surgery (P = 0.47). After adjusting for confounders, factors associated with risk of placenta praevia were history of retained placenta [OR = 6.7(95% CI 1.2-36.6)], previous caesarean section [OR = 4.7, (95% CI 1.9-11.4)], previous abortion [OR = 2.9 (95% CI 1.1-5.1)], grand multiparity [OR = 2.1 (95% CI 1.6-7.1)] and age over 35 years [OR = 1.4 (95% CI 1.2-6.6)]. CONCLUSIONS: From our study, the risk factors for placenta praevia are a history of retained placenta, previous caesarean section, previous abortion, grand multiparity and maternal age over 35 years.
Abortion, Induced↗
Path analysis for seven postpartum disorders of Holstein cows.
Path analysis and multiple logistic regression with an extrabinomial variation error term (to account for herd) were used to model seven postpartum clinical disorders of dairy cows and factors related to the calf. Data were from 7761 lactation records from 34 commercial herds in the vicinity of Cornell University. Stillbirth increased the odds of developing metritis and retained placenta. The odds of developing dystocia and mastitis were lower when the sex of the calf was female. However, cows that twinned had increased odds of developing dystocia and retained placenta. Dystocia was related to an increase in the odds of retained placenta. Milk fever, dystocia, and ketosis each increased the odds of developing left-displaced abomasum. Postpartum periods with dystocia, retained placenta, or ketosis had increased odds of metritis. Two interaction terms involved parity: stillbirth for milk fever and retained placenta for ketosis. The extrabinomial variation error term contributed to the fit in all models.
Animals↗
Heritabilities of and genetic correlations among six health problems in Holstein cows.
Information from 7712 lactations of Holstein dairy cows was collected from 33 commercial herds around Ithaca, NY in the 3 yr from 1981 to 1983. The data were divided into subsets corresponding to lactation 1, lactation 2, and lactation 3 or greater. To estimate heritabilities of dystocia, retained placenta, metritis, ovarian cysts, milk fever, and mastitis, a mixed linear model (herd-year fixed and sire random effects) with 0 or 1 as the observed response was used. Variance components were estimated using Henderson's Method 3. The results show moderate heritabilities (.15 to .40) for dystocia, metritis, milk fever, and mastitis and low heritability (less than .12) for retained placenta and cystic ovaries. Genetic correlations between dystocia, retained placenta, metritis, and mastitis were moderate in size and positive, whereas cystic ovaries were correlated negatively with dystocia and retained placenta. A general reproductive health trait (dystocia, retained placenta, metritis, cystic ovaries, and milk fever combined in one trait) also was analyzed. The estimated heritability of this trait was .21, .11, and .00 for first calf heifers, second lactation cows, and older cows, respectively.
Animals↗
Periparturient traits in seven high dairy herds. Incidence rates, association with parity, and interrelationships among traits.
Interrelationships among nine periparturient traits and their association with parity were investigated in 8521 calvings of dairy cows examined routinely between 5 to 14 d postpartum. Rates of twins, stillbirth, milk fever, prolapsed uterus, retained placenta, primary metritis, displaced abomasum, ketonuria, and aciduria were 5.8, 6.3, 1.4, 3, 17.8, 36.1, 1.7, 30.4, and 29.5%, respectively. The risk for twins, milk fever, prolapsed uterus, displaced abomasum, ketonuria, and aciduria increased with parity, whereas that for stillbirth and metritis was higher in heifers than in cows. Stillbirth, retained placenta, metritis, displaced abomasum, ketonuria, and aciduria were directly associated with birth of twins; prolapsed uterus and retained placenta with stillbirth; prolapsed uterus, retained placenta, and primary metritis with milk fever; displaced abomasum, ketonuria, and aciduria with retained placenta and with metritis; ketonuria and aciduria with displaced abomasum and aciduria with ketonuria.
Abomasum↗
Nonlinear mixed model analyses of five production disorders of dairy cattle.
A standardized threshold model was used to estimate herd variability and the impact of some risk factors on the incidence of retained placenta, metritis, ketosis, ovulatory dysfunction, and mastitis. Data consisted of records for 18,110 Swedish Red and White cows in 924 herds and 14,940 Swedish Friesian cows in 772 herds. Only first, second, and third party cows were included, and the breeds were analyzed separately. Herds were considered to be random effects, and variance components were estimated by the counterpart of REML for a threshold model. Estimated intraherd correlations varied from .04 to .18 and were lowest for the incidence of retained placenta (for both breeds) and highest for ketosis and ovulatory dysfunction for Swedish Red and White and Swedish Friesian breeds, respectively. Parity increased predicted lactational incidence risks for all disorders except metritis, but season of calving had no profound effect. Dystocia and stillbirth increased the risk of retained placenta; dystocia and retained placenta increased the risk of metritis. The risk of ketosis was not influence by any of the considered risk factor diseases, and the risk of mastitis was influenced only by retained placenta for Swedish Red and White cows. For both breeds, the risk of ovulatory dysfunction was increased by metritis and ketosis.
Animals↗
Histopathology of retained bovine fetal membranes.
Placentomes were obtained from 20 cows with retained placenta (9 following normal birth, 5 after abortion and 6 with dystocia), and this material was examined by light microscopy. Histologic changes that were consistently seen in placentomes of cows with retained placenta after normal birth included vascular changes (edema, thrombosis and vasculitis) and the presence of numerous clumps of bacterialcolonies in the connective tissue of the caruncles and cotyledons. Only a few binucleate cells were seen in these cases. In placentomes obtained from cows with retained placenta after abortion, there were instances of focal necrosis of the fetal villi and the presence of variable numbers of binucleate cells. Vascular changes and numerous clumps of bacterial colonies in the caruncles and cotyledons were also noted. The changes in placentomes obtained from cows with retained placenta and dystocia included the presence of numerous binucleate cells, infiltration of polymorphonuclear cells in the connective tissue of both the fetal and maternal villi, vascular changes, and the presence of extensive necrosis and numerous clumps of bacterial colonies. Significant differences (P < 0.05) were encountered in the number of binucleate cells in the various groups. Binucleate cells appear to be involved in the process of placental separation in cows with retained placenta.
Journal Article↗
The use of intravenous nitroglycerin for cervico-uterine relaxation: a review of the literature.
The safety, predictability, and ease of intravenous administration of nitroglycerin (NTG) have been firmly documented. In recent years, intravenous NTG has come to the attention of the obstetrician as a potent uterine relaxant. Intravenous nitroglycerin has been used to relax the uterus during manual extraction of retained placenta and to permit replacement of a contracted, completely prolapsed, inverted uterus. The use of this agent as a tocolytic has previously been reported in cesarean delivery of twins, in cases of intra partum external cephalic version, and for internal intrapartum podalic version of the second twin. This new procedure was also used for fetal head entrapment after vaginal breech delivery. The authors report a review of the literature about this subject.
Breech Presentation↗
Management of a parturient with paroxysmal nocturnal haemoglobinuria.
We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.
Adult↗