Skip to main content
SpringerLink
Log in

Failed manual removal of the placenta after vaginal delivery

  • Maternal-Fetal Medicine
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

A retained placenta after vaginal delivery where manual removal of placenta fails is a clinical challenge. We present six cases that illustrate the heterogeneity of the condition and discuss the etiology and terminology as well as the clinical management.

Methods

Members of the European Working group on Abnormally Invasive Placenta (EW-AIP) were invited to report all recent cases of retained placenta that were not antenatally suspected to be abnormally adherent or invasive, but could not be removed manually despite several attempts.

Results

The six cases from Denmark, The Netherlands and the UK provide examples of various treatment strategies such as ultrasound-guided vaginal removal, removal of the placenta through a hysterotomy and just leaving the placenta in situ. The placentas were all retained, but it was only possible to diagnose abnormal invasion in the one case, which had a histopathological diagnosis of increta. Based on these cases we present a flow chart to aid clinical management for future cases.

Conclusion

We need properly defined stringent terminology for the different types of retained placenta, as well as improved tools to predict and diagnose both abnormally invasive and abnormally adherent placenta. Clinicians need to be aware of the options available to them when confronted by the rare case of a retained placenta that cannot be removed manually in a hemodynamically stable patient.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Evensen A, Anderson JM, Fontaine P (2017) Postpartum hemorrhage: prevention and treatment. Am Fam Physician 95(7):442–449

    PubMed  Google Scholar 

  2. Herman A (2000) Complicated third stage of labor: time to switch on the scanner. Ultrasound Obstet Gynecol 15(2):89–95

    Article  CAS  PubMed  Google Scholar 

  3. Collins SL, Stevenson GN, Al-Khan A, Illsley NP, Impey L, Pappas L et al (2015) Three-dimensional power Doppler ultrasonography for diagnosing abnormally invasive placenta and quantifying the risk. Obstet Gynecol 126(3):645–653

    Article  PubMed  Google Scholar 

  4. Bennett MJ, Townsend L (2009) Conservative management of clinically diagnosed placenta accreta following vaginal delivery. Aust N Z J Obstet Gynaecol 49(6):647–649

    Article  PubMed  Google Scholar 

  5. Lee D, Johnson J (2012) Hysterotomy for retained placenta in a septate uterus: a case report. Case Rep Obstet Gynecol 2012:594140

    PubMed  PubMed Central  Google Scholar 

  6. Shekhar S, Verma S, Motey R, Kaushal R (2010) Hysterotomy for retained placenta with imminent uterine rupture in a preterm angular pregnancy. Acta Obstet Gynecol Scand 89(12):1615–1616

    Article  PubMed  Google Scholar 

  7. Silver RM, Barbour KD (2015) Placenta accreta spectrum: accreta, increta, and percreta. Obstet Gynecol Clin North Am 42(2):381–402

    Article  PubMed  Google Scholar 

  8. Sentilhes L, Ambroselli C, Kayem G, Provansal M, Fernandez H, Perrotin F et al (2010) Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol 115(3):526–534

    Article  PubMed  Google Scholar 

  9. Chongsomchai C, Lumbiganon P, Laopaiboon M (2014) Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. Cochrane Database Syst Rev 10:CD004904

    Google Scholar 

  10. Endler M, Grunewald C, Saltvedt S (2012) Epidemiology of retained placenta: oxytocin as an independent risk factor. Obstet Gynecol 119(4):801–809

    Article  PubMed  Google Scholar 

  11. Owolabi AT, Dare FO, Fasubaa OB, Ogunlola IO, Kuti O, Bisiriyu LA (2008) Risk factors for retained placenta in southwestern Nigeria. Singap Med J 49(7):532–537

    CAS  Google Scholar 

  12. Adelusi B, Soltan MH, Chowdhury N, Kangave D (1997) Risk of retained placenta: multivariate approach. Acta Obstet Gynecol Scand 76(5):414–418

    Article  CAS  PubMed  Google Scholar 

  13. Combs CA, Laros RK Jr (1991) Prolonged third stage of labor: morbidity and risk factors. Obstet Gynecol 77(6):863–867

    CAS  PubMed  Google Scholar 

  14. Coviello EM, Grantz KL, Huang CC, Kelly TE, Landy HJ (2015) Risk factors for retained placenta. Am J Obstet Gynecol 213(6):864 e1–864 e11

    Article  Google Scholar 

  15. Ashwal E, Melamed N, Hiersch L, Wiznitzer A, Yogev Y, Peled Y (2014) The incidence and risk factors for retained placenta after vaginal delivery—a single center experience. J Matern Fetal Neonatal Med 27(18):1897–1900

    Article  PubMed  Google Scholar 

  16. Belachew J, Cnattingius S, Mulic-Lutvica A, Eurenius K, Axelsson O, Wikstrom AK (2014) Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study. BJOG 121(2):224–229

    Article  CAS  PubMed  Google Scholar 

  17. Panpaprai P, Boriboonhirunsarn D (2007) Risk factors of retained placenta in Siriraj Hospital. J Med Assoc Thai 90(7):1293–1297

    PubMed  Google Scholar 

  18. Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A (2011) The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. Hum Reprod Update 17(6):761–771

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Chan YY, Jayaprakasan K, Tan A, Thornton JG, Coomarasamy A, Raine-Fenning NJ (2011) Reproductive outcomes in women with congenital uterine anomalies: a systematic review. Ultrasound Obstet Gynecol 38(4):371–382

    Article  CAS  PubMed  Google Scholar 

  20. Fox NS, Roman AS, Stern EM, Gerber RS, Saltzman DH, Rebarber A (2014) Type of congenital uterine anomaly and adverse pregnancy outcomes. J Matern Fetal Neonatal Med 27(9):949–953

    Article  PubMed  Google Scholar 

  21. Hiersch L, Yeoshoua E, Miremberg H, Krissi H, Aviram A, Yogev Y et al (2016) The association between Mullerian anomalies and short-term pregnancy outcome. J Matern Fetal Neonatal Med 29(16):2573–2578

    CAS  PubMed  Google Scholar 

  22. Vaz SA, Dotters-Katz SK, Kuller JA (2017) Diagnosis and management of congenital uterine anomalies in pregnancy. Obstet Gynecol Surv 72(3):194–201

    Article  PubMed  Google Scholar 

  23. Wright CE, Chauhan SP, Abuhamad AZ (2014) Bakri balloon in the management of postpartum hemorrhage: a review. Am J Perinatol 31(11):957–964

    Article  PubMed  Google Scholar 

  24. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S (2007) Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 62(8):540–547

    Article  PubMed  Google Scholar 

  25. Georgiou C (2009) Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 116(6):748–757

    Article  CAS  PubMed  Google Scholar 

  26. Kayem G, Kurinczuk JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M (2011) Specific second-line therapies for postpartum haemorrhage: a national cohort study. BJOG 118(7):856–864

    Article  CAS  PubMed  Google Scholar 

  27. Laas E, Bui C, Popowski T, Mbaku OM, Rozenberg P (2012) Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage. Am J Obstet Gynecol. 207(4):281 e1–281 e7

    Article  Google Scholar 

  28. Revert M, Cottenet J, Raynal P, Cibot E, Quantin C, Rozenberg P (2016) Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort study. BJOG 124(8):1255–1262. doi:10.1111/1471-0528.14382

    Article  PubMed  Google Scholar 

  29. D’Antonio F, Palacios-Jaraquemada J, Lim PS, Forlani F, Lanzone A, Timor-Tritsch I et al (2016) Counseling in fetal medicine: evidence-based answers to clinical questions on morbidly adherent placenta. Ultrasound Obstet Gynecol 47(3):290–301

    Article  PubMed  Google Scholar 

  30. Ruiz Labarta FJ, Pintado Recarte MP, Alvarez Luque A, Joigneau Prieto L, Perez Martin L, Gonzalez Leyte M et al (2016) Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review. Eur J Obstet Gynecol Reprod Biol 206:12–21

    Article  CAS  PubMed  Google Scholar 

  31. Cirpan T, Sanhal CY, Yucebilgin S, Ozsener S (2011) Conservative management of placenta previa percreta by leaving placental tissue in situ with arterial ligation and adjuvant methotrexate therapy. J Turk Ger Gynecol Assoc 12(2):127–129

    Article  PubMed  PubMed Central  Google Scholar 

  32. Heiskanen N, Kroger J, Kainulainen S, Heinonen S (2008) Placenta percreta: methotrexate treatment and MRI findings. Am J Perinatol 25(2):91–92

    Article  PubMed  Google Scholar 

  33. Lalchandani S, Geary M, O’Herlihy C, Sheil O (2003) Conservative management of placenta accreta and unruptured interstitial cornual pregnancy using methotrexate. Eur J Obstet Gynecol Reprod Biol 107(1):96–97

    Article  CAS  PubMed  Google Scholar 

  34. Mussalli GM, Shah J, Berck DJ, Elimian A, Tejani N, Manning FA (2000) Placenta accreta and methotrexate therapy: three case reports. J Perinatol 20(5):331–334

    Article  CAS  PubMed  Google Scholar 

  35. Pinho S, Sarzedas S, Pedroso S, Santos A, Rebordao M, Avillez T et al (2008) Partial placenta increta and methotrexate therapy: three case reports. Clin Exp Obstet Gynecol 35(3):221–224

    CAS  PubMed  Google Scholar 

  36. Lim BH, Palacios-Jaraquemada JM (2015) The morbidly adherent placenta—a continuing diagnostic and management challenge. BJOG 122(12):1673

    Article  PubMed  Google Scholar 

  37. Tikkanen M, Paavonen J, Loukovaara M, Stefanovic V (2011) Antenatal diagnosis of placenta accreta leads to reduced blood loss. Acta Obstet Gynecol Scand 90(10):1140–1146

    Article  PubMed  Google Scholar 

  38. Bhide A, Sebire N, Abuhamad A, Acharya G, Silver R (2017) Morbidly adherent placenta: the need for standardization. Ultrasound Obstet Gynecol 49(5):559–563

    Article  CAS  PubMed  Google Scholar 

  39. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadottir RI et al (2016) Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. BJOG 123(8):1348–1355

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen OE, Denmark

    Johanna Bjurström, Jens Langhoff-Roos & Lene Groenbeck

  2. Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK

    Sally Collins

  3. Department of Fetal Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen OE, Denmark

    Karin Sundberg

  4. Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark

    Annemette Jørgensen

  5. Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands

    Johannes J. Duvekot

Authors
  1. Johanna Bjurström
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sally Collins
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jens Langhoff-Roos
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Karin Sundberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Annemette Jørgensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Johannes J. Duvekot
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lene Groenbeck
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

For the EW-AIP

Contributions

The authors all take responsibility for the paper as published. JB: protocol/project development, data collection, manuscript writing. SC: data collection, manuscript editing. JL-R: protocol/project development, data collection, manuscript editing. KS: data collection, manuscript editing. AJ: data collection, manuscript editing. JJD: protocol/project development, data collection, manuscript editing. LG: protocol/project development, data collection, manuscript editing.

Corresponding author

Correspondence to Johanna Bjurström.

Ethics declarations

Funding

This study received no funding.

Conflict of interest

The authors declare that they have no conflicts of interests to disclose.

Ethical approval

Informed consent to publish patient histories in an anonymous form was obtained from all six patients included. Therefore, approval from national ethics committees is not needed.

Additional information

The European Working group on Abnormally Invasive Placenta, EW-AIP, is a collaboration from 11 European university hospitals working in the field of abnormally invasive placentation. The EW-AIP was founded in 2008, their website is at http://www.ew-aip.org.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bjurström, J., Collins, S., Langhoff-Roos, J. et al. Failed manual removal of the placenta after vaginal delivery. Arch Gynecol Obstet 297, 323–332 (2018). https://doi.org/10.1007/s00404-017-4579-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-017-4579-2

Keywords

Search

Navigation