Failed manual removal of the placenta after vaginal delivery

Laparoscopic Management of a Trapped Placenta Following Normal Delivery in a Woman With a Mullerian Anomaly

Entrapped placenta following vaginal delivery is an uncommon complication. In resistant cases, it needs to be removed by laparotomy, although this is exceptionally rare. Here, we report a 28-year-old woman, 33 weeks pregnant through in vitro fertilization, who delivered a premature male baby weighing 2400 grams with an Apgar score of 7. After delivery, the placenta remained in the unicornuate uterus. Ultrasound ruled out placenta accreta spectrum, and manual removal attempts under anesthesia failed due to lower uterine segment contraction despite using nitroglycerine. Conservative management with misoprostol and broad-spectrum antibiotics was initiated. However, increasing C-reactive protein levels and abdominal pain necessitated a computerized tomography scan, revealing the placenta trapped in the unicornuate uterus. Thirty-six hours after the delivery, the decision was made to remove the placenta laparoscopically instead of laparotomy. A unicornuate uterus containing a placenta on the right and the left rudimentary horn connected to the right uterus with bilateral adnexa, including theca cysts, were revealed during laparoscopic observation. No pelvic organ injury was noted. The placenta was removed via a fundal incision with a monopolar hook and using claw traumatic forceps. The uterus was closed with V-lock sutures; additional Z-sutures were applied. A 270-gram entire placenta was extracted using an endo bag successfully. The patient was discharged several days after the procedure without any complications. Laparoscopic extraction of a third-trimester placenta can successfully be used in resistant cases while avoiding laparotomy, even in the early postpartum period.

Fundal partial placenta percreta complicated with postpartum hemoperitoneum: A case report

INTRODUCTION

The fundus of the uterus is a rare location for abnormally invasive placenta compared with the common site of abnormally invasive placenta in the lower segment of the uterus.

PRESENTATION OF CASE

We report a case of a 38-year-old multipara woman who had a fundal partial placenta percreta with no prior cesarean sections, which presented as a retained placenta after preterm labor, and complicated with hemorrhagic shock due to postpartum hemoperitoneum, thus it was diagnosed after surgery and managed by subtotal hysterectomy.

DISCUSSION

We discuss the most common risk factors for abnormally invasive placenta and its diagnosis and management. We compare the possibility of leading to invasive placenta resulting from curettage trauma and cesarean delivery scars.

CONCLUSION

History of uterine surgical procedures without prior cesarean delivery must raise suspicion of abnormally invasive placenta regardless of its localization, especially when associates with preterm labor or retained placenta.

Retained placenta after vaginal delivery: risk factors and management

Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.