The Occasional Retained Placenta: Now What Happens? The Use of Intra-umbilical Uterotonics for Retained Placenta

My Practicum in Penticton… Penticton Regional Hospital (Interior Health) Population 33,000 (catchment = 90,000) Births in 2014-2015 year = 514 (PSBC) Primary Care Providers: RMW, GP, OB Other team members: Nursing, Pediatrics, Anesthesia, OR, MW Students & Residents

Retained Placenta: What is it & Why does it happen? Definition: third stage greater than 30 minutes (98% of placentas will deliver by this time – Uptodate) Failure of the placenta to separate and/or expel from the uterus Pathogenesis (Third Stage) 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. Types of retained placenta: Trapped or incarcerated placenta Placenta adherens Placenta accreta

Retained Placenta: Who & How Often? Risk factors: previous retained placenta, preterm delivery, prolonged oxytocin use, preeclampsia, and greater than or equal to two miscarriages or abortions (MoreOB) Fifty per cent of placentas deliver within five minutes and 90% within 15 minutes of the baby’s birth (MoreOB) – so not very often

Retained Placenta: Why does it matter? #1 risk factor for PPH (Uptodate) Risk of PPH increases three fold if the placenta is delivered after fifteen minutes as compared to before 15 minutes (MoreOB) Risk of transfusion was three-fold greater when the placenta delivery time exceeded 30 minutes (MoreOB)

Retained Placenta: What can we do? Active management of third stage: IM oxytocin with delivery of shoulder & controlled cord traction (includes skin to skin) Anticipate PPH/Get help when indicated Ensure IV Access if placenta not delivered within 15 minutes (MoreOB) After 15 minutes consider intra-umbilical oxytocin or misoprostol administration If intra-umbilical oxytocin not successful then manual removal if/when indicated Manual removal of a retained placenta may lead to complications such as infection, uterine perforation, hemorrhage, and maternal discomfort (MoreOB)

What does the evidence say? “UVI of oxytocin solution is an inexpensive and simple intervention that could be performed while placental delivery is awaited. However, high-quality randomized trials show that the use of oxytocin has little or no effect. Further research into the optimal timing of manual removal and into UVI of prostaglandins or plasma expander is warranted” (Cochrane, 2011) “Intra-umbilical injection of misoprostol may be of benefit but data are limited” (MoreOB) So….. What makes sense for our site?

Intra-Umbilical Oxytocin Procedure Explain the procedure and obtain consent Using a 20cc syringe, mix 20 units of Oxytocin in 20mls of Normal Saline Identify the umbilical vein. Recut the cord if necessary Insert a size 8Fr nasogastric tube into the umbilical vein. If resistance is felt, retract the catheter by 1-2cm and then advance further, if possible The tube has reached the placenta when the majority of the catheter is inserted and resistance is felt. (The lengths of the umbilical cords varied between 30-47cm in the Rogers’ study) Retract by 3-4cm to ensure that the tip is in the umbilical vein and not in a placental branch Attach the syringe and inject the solution followed by clamping the cord with the catheter Note the time of injection Wait 10-30 minutes for the placenta to deliver Source: Penticton Regional Hospital

Intra-Umbilical Misoprostol Procedure Explain the procedure and obtain consent Prepare a syringe with the medication in 30 cc normal saline. Crush and dissolve 4x 200 mcg tablets misoprostol in 30 ml normal saline (forms milky solution). Identify the umbilical vein.  Recut the cord if necessary. Insert a size 10 nasogastric tube into the umbilical vein.  If resistance is felt, retract the catheter by 1–2 cm and then advance further, if possible. The tube has reached the placenta when the majority of the catheter is inserted and resistance is felt. (The lengths of the umbilical cords varied between 30–47 cm in the Rogers’ study)80 Retract by 3–4 cm to ensure that the tip is in the umbilical vein and not in a placental branch. Attach the syringe and inject the solution followed by clamping of the cord with the catheter. Note the time of the injection. Wait 10–30 minutes for the placenta to deliver. Source: MoreOB

Video “Umbilical vein injection for retained placenta: why and how?” https://www.youtube.com/watch?v=QLND6Ovld60

Thank you! References Belfort, MA (2016). Uptodate: Overview of postpartum hemorrhage MoreOB (2016). Postpartum Hemorrhage Nardin JM, Weeks A, Carroli G (2011). Cochrane Review: Umbilical vein injection for management of retained placenta