Relationship between hypocalcemia immediately after calving with metabolic disorders and body condition score in Holstein cows

Background

Hypocalcemia is one of the most common transition period disorders that affects dairy cows and has been divided into clinical and subclinical types.

Aim

This study aimed to investigate the relationship between postpartum serum calcium (Ca) concentrations with metabolic disorders and body condition score (BCS) in Holstein dairy cows.

Methods

Two hundred and seventy-one Holstein cows were blocked from two commercial dairy herds based on parity (primiparous and multiparous) and serum Ca concentrations on calving day, 1 and 2 days postpartum were allocated to 1 of 3 groups: 1) Serum Ca concentration >8.5 mg/dl at the calving day, 1 and 2 days postpartum (normocalcemic); 2) serum Ca concentration ≤8.5 mg/dl on the calving day and 1 or 2 day postpartum (transient subclinical hypocalcemia (TSCH)); and 3) serum Ca concentration ≤8.5 mg/dl on the calving day, 1 and 2 days postpartum (persistent subclinical hypocalcemia (PSCH)).

Results

The results showed that the primiparous and multiparous cows had the highest TSCH and PSCH percentages, respectively. Ca status after calving did not affect the BCS changes, incidence of milk fever, hypomagnesemia and hyperketonemia, and clinical and subclinical endometritis. The incidence of retained placenta, metritis, and subclinical mastitis was affected by Ca status after calving, so PSCH cows experienced 6.28, 6.43, and 5.9 times more retained placenta, metritis, and subclinical mastitis than normocalcemic cows, respectively. The culling rate within the first 60 days in milk for PSCH cows was 4.61 times more than for normocalcemic cows.

Conclusion

Overall, the results of the study showed that cows with PSCH had a higher incidence of retained placenta; uterine infections, subclinical mastitis, and culling rate, but cows with TSCH were similar to healthy cows in terms of metabolic disorders and culling rate.

A rare case of morbidly adherent placenta in a young Primigravida with RH negative pregnancy managed with peripartum subtotal hysterectomy

INTRODUCTION AND IMPORTANCE

Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause of maternal mortality rate. Prevention and early intervention can prevent this complication of delivery. However condition like placenta accreta leads to retention of placenta and makes PPH inevitable.

CASE SUMMARY

We present the case of massive postpartum hemorrhage secondary to Placenta accreta in young primigravida with RH negative pregnancy. Clinical findings and investigations were not significant during her admission. She delivered the baby via vaginal route but placenta was not expelled till 30 min. Due to failed manual removal of placenta patient was shifted to OT.Manual vacuum aspiration was done in OT setting and chunks of placenta along with blood clots were obtained.Uterine balloon tamponade was inserted. Due to persistent PV bleeding subtotal hysterectomy was carried out in line for placenta accreta.

DISCUSSION

Placenta accreta being one of the life threatening obstetric condition, it should be diagnosed as early as possible and need prompt management so as to prevent maternal mortality. Due to increasing number of cesarean delivery the cases of placenta accreta has been rising but rarely in some cases can it present in young primigravida with Rh negative pregnancy.

CONCLUSION

In the cases of morbidly adherent placenta it is necessary for obstetrician to early identify such conditions and timely intervene to save the mother's life. Moreover Rh negative could be a hidden risk factor.

Racial and ethnic disparities in the incidence, healthcare utilization, and outcomes of retained placenta among delivery hospitalizations in the United States, 2016-2019

BACKGROUND

Retained placenta is a concern during labor and delivery. However, recent data regarding the profiles of retained placenta are scarce, especially nationwide and in minority populations. This study aimed to investigate the recent incidence of retained placenta and its associated outcomes.

METHODS

We retrospectively analyzed an American population-based data from the National Inpatient Sample (NIS) 2016-2019. The outcomes of interest included the incidence of retained placenta, in-hospital mortality, length of hospital stay, and hospitalization costs. We estimated the incidence for retained placenta overall and by racial and ethnic subgroups, utilizing survey weights standardized for each subgroup. Multivariable linear or logistic regression models were employed in our study to investigate the associations between retained placenta and the impact of in-hospital mortality, duration of stay, and hospitalization expenditures for the entire population and further stratified by race and ethnicity, adjusting for potential confounders.

RESULTS

Of the 13,848,131 deliveries, there were 108,035 (or 0.78%) birthing persons were identified as having retained placentas. Over time, the incidence of retained placenta increased from 730 per 100,000 (0.73%) in 2016 to 856 per 100,000 (0.86%) in 2019. Native American mothers have the highest rate of retained placenta, with a prevalence almost twice that of the general population, reaching 1,434 cases per 100,000 (1.43%). After adjusting for confounding factors, Native American mothers were more likely to have retained placenta (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.35-1.81), whereas Black (OR, 0.92; 95% CI, 0.88-0.97) and Hispanic mothers (OR, 0.84; 95% CI, 0.80-0.89) were significantly less likely to have retained placenta than White mothers. Furthermore, those who delivered with a retained placenta were significantly associated with higher in-hospital mortality, a longer duration of stay, and hospitalization expenditures, which were disproportionately varied by maternal race and ethnicity.

CONCLUSIONS

The incidence of retained placenta among people undergoing vaginal delivery is exhibiting an upward trend over time, with notable variations observed across different ethnic groups by unclear mechanisms. The ramifications of these findings have the potential to impact the clinical management of maternal health care and the creation of health policies, specifically in relation to the Native American birth population.

Different protocols in treatment of placental retention in dairy cows and their influences on reproductive performance

The study aimed to evaluate the effect of α-chymotrypsin on placental separation as a treatment protocol for retained placenta (RP) in dairy cows and its effect on reproductive performance after placental shedding. The study was conducted on 64 crossbred cows that suffered from retained placenta. Cows were divided into four equal groups: group I (n=16) treated with prostaglandin F2α (PGF2α); group II (n=16) treated with PGF2α in combination with α-chemotrypsin; group III (n=16) treated with α-chemotrypsin only and group IV (n=16) treated by manual removal of the RP. Cows were under observation after treatment till placental shedding. Placental samples were taken from the non-responsive cows after the course of treatment and examined to observe the histopathological changes in each group. Results revealed that the time of placental dropping showed a significant decrease in group II compared to other groups. Histopathological examination of group II shows that collagen was found as fewer fibers in scattered areas and necrosis appeared as numerous areas widespread in the fetal villi. A few inflammatory cells were infiltrated in the placental tissue and the vascular changes appear as mild vasculitis and mild edema. Cows in group II have rapid uterine involution, decreased risk of postpartum metritis and improved reproductive performance. It is concluded that PGF2α in combination with α- chemotrypsin is the recommended treatment for RP in dairy cows. This recommendation is warranted, as this treatment was successful in achieving rapid placental shedding, rapid uterine involution, a decreased risk of postpartum metritis and improved reproductive performance.

Gene expression profile of placentomes and clinical parameters in the cows with retained placenta

BACKGROUND

Retained placenta (RP) is a prevalent disorder in cattle with many health-related and economic costs for the farm owners. Its etiology has not been clarified yet and there is no definite therapy for this disorder. In this study we conducted RNA-seq, hematologic and histologic experiments to survey the causes of RP development.

METHODS

Blood samples were collected from 4 RP and 3 healthy cows during periparturtion period for hematological assessments followed by placentome sampling within 30 min after parturition. Cows were grouped as RP and control in case the placenta was retained or otherwise expelled, respectively. Total RNA was extracted from placentome samples followed by RNA-sequencing.

RESULTS

We showed 240 differentially expressed genes (DEGs) between the RP and control groups. Enrichment analyzes indicated immune system and lipid metabolism as prominent over- and under-represented pathways in RP cows, respectively. Hormonal assessments showed that estradiol-17β (E2) was lower and cortisol tended to be higher in RP cows compared to controls at the day of parturition. Furthermore, histologic experiment showed that villi-crypt junctions remain tighter in RP cows compared to controls and the crypts layer seemed thicker in the placentome of RP cows. Complete blood cell (CBC) parameters were not significantly different between the two groups.

CONCLUSION

Overall, DEGs derived from expression profiling and these genes contributed to enrichment of immune and lipid metabolism pathways. We suggested that E2 could be involved in development of RP and the concentrations of P4 and CBC counts periparturition might not be a determining factor.

Post-partum choriocarcinoma mimicking retained adherent placental remnants: A rare case report

Patients with post-partum choriocarcinoma have poorer prognosis than those with hydatidiform mole due to metastasis and delayed diagnosis. We report a rare case of post-partum choriocarcinoma manifesting as retained placental remnants caused by placental adhesion, wherein a delay in diagnosis occurred due to failure of serum human chorionic gonadotrophin (hCG) surveillance and pathological examination of the placenta or curettage tissues. In summary, it is important to pay more attention to retained adherent placental remnants by pathological examination for abnormal placenta and β-hCG surveillance for retained placenta to shorten the interval between antecedent pregnancy and diagnosis.

Placental cord drainage and its outcomes at third stage of labor: a randomized controlled trial

BACKGROUND

The third stage of labor begins with the baby's birth and ends with the expulsion of the placenta and embryonic membranes. The prolongation of the third stage of labor, placental retention, subsequent issues such as postpartum hemorrhage, and manual removal of the placenta have adverse outcomes, which eventually affect the positive experience of delivery. The present study aimed to assess the effect of placental cord drainage on the duration of the third stage of labor and to clarify its effects on postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta.

METHODS

This study was a parallel-group randomized trial. Four hundred women in the third stage of labor after vaginal delivery were randomized into the drainage (placenta drainage, n = 200) and the control groups (no placenta drainage, n = 200). In both groups, the third stage of labor was performed with the active method, and the placenta was removed using the Brandt-Andrews maneuver with maternal pushing. The duration of the third stage was compared between the two groups as the primary outcome. Also, the incidence of postpartum hemorrhage, retained placenta, and manual removal of placenta was compared.

RESULTS

In all, 175 women in the drainage group and 165 women in the control group were included in the analysis. The third stage of labor was significantly shorter after placental cord drainage. The mean duration of the third stage was 7.09 ± 1.01 minutes in the drainage group, and it was 10.43 ± 3.20 minutes in the control group (P < 0.001). Postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta in the drainage group was significantly less than in the control group.

CONCLUSION

Placental cord drainage is a simple and non-invasive method of reducing the duration of the third stage of labor. This method does not increase postpartum complications.

TRIAL REGISTRATION

IRCT2014041917341N1 , retrospectively registered at 15. 10. 2017.

Latest update on predictive indicators, risk factors, and 'Omic' technologies research of retained placenta in dairy cattle- review article

Retained placenta is a pathological condition defined as failure to expel fetal membranes within 12 -24h after parturition. It instigates important financial losses to the dairy industry causing considerable economic loss. It is a multifactorial disorder. Although different hypotheses have been proposed, contradictory results and no single factor explains the development of the disease. This indicates that there are overall significant gaps in our knowledge about the various factors affecting the etiopathology and pathobiology of the retained placenta. Thus, it will be of great interest to investigate the potential contributing factors that influence the occurrence of RP which provide us with the mechanisms to avoid the occurrence of the disease. In addition, different predictive indicators of RP should be part of our research, thus providing the essential procedures applied to deal with the disease and the development of novel therapeutic and prophylactic strategies in its management. Furthermore, lately, the molecular role takes attention to understanding its effect in the occurrence of the disease. Such information might help dairy scientists in the future to design better management and preventive practices for RP in dairy cows.

Angiographic features and transarterial embolization of retained placenta with abnormal vaginal bleeding

Objectives

To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding.

Methods

The study cohort comprised 22 patients (mean age, 33.5 years; range, 22–24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated.

Results

Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial–capillary phase in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1–17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients.

Conclusions

The characteristic angiographic feature of retained placenta is “dilated vascular channel that mimic low flow AVM.” TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.

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.

The RPOC long axis is a simple indicator for predicting the need of invasive strategies for secondary postpartum hemorrhage in either post-abortion or post-partum women: a retrospective case control study

Background

The retained products of conception (RPOC) and related conditions (RPOC-ARC) are the main cause of secondary postpartum hemorrhage (sPPH), but there is no clear consensus for their management. The purpose of this study was to characterize those RPOC-ARC that require invasive treatment and those that could be managed more conservatively.

Methods

We retrospectively analyzed 96 cases of RPOC-ARC that occurred after miscarriage, abortion, or delivery at a gestational age between 12 and 42 completed weeks, that were managed within our institution from May 2015 to August 2020. We reviewed the associations between the occurrence of sPPH requiring invasive treatment with clinical factors such as the maternal background and the characteristics of the lesions.

Results

The range of gestational age at delivery in our study was 12–21 weeks in 61 cases, 22–36 in 5, and 37 or later in 30. Among them, nine cases required invasive procedures for treatment. The onset of sPPH was within one month of delivery in all but two cases, with a median of 24 days (range 9–47). We found significant differences between requirements for invasive versus non-invasive strategies according to gestational age at delivery, assisted reproductive technology (ART) pregnancy, amount of blood loss at delivery, and the long axis of the RPOC-ARC lesion (p = 0.028, p = 0.009, p = 0.004, and p = 0.002, respectively). Multivariate analysis showed that only the long axis of the lesion showed a significant difference (p = 0.029). The Receiver Operating Characteristic (ROC) curve for predicting the need for invasive strategies using the long axis of the lesion showed that with a cutoff of 4.4 cm, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was 87.5, 90.0, 43.8, and 98.7%, respectively.

Conclusion

The long axis of the RPOC-ARC is a simple indicator for predicting which sPPH will require invasive procedures, which use is rare in cases with lesions less than 4.4 cm or those occurring after the first postpartum month. Conservative management should be considered in such cases.

Risk factors for non-adherent retained placenta after vaginal delivery: a systematic review

Background

Retained placenta represents a cause of maternal morbidity and mortality affecting 0.5–3% of all vaginal deliveries. The unpredictability of this condition makes difficult to develop predictive and preventive strategies to apply in clinical practice. This analysis collected and analyzed all known risk factors related to this obstetric complication.

Methods

A systematic literature review for all original research articles published between 1990 and 2020 was performed. Observational studies about retained placenta risk factors published in English language were considered eligible. Conference abstracts, untraceable articles and studies focused on morbidly adherent placenta were excluded. The included articles were screened to identify study design, number of enrolled patients and retained placenta risk factors investigated. All stages of the revision followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

Results

Thirty-five studies met the inclusion criteria. The reported retained placenta prevalence ranged from 0.5 to 4.8%. Maternal age, previous cesarean sections, previous dilation and curettage, previous retained placenta, labor induction, resulted as the most recurrent, independent risk factors for retained placenta. Previous estro-progestins therapy, morphological placental features (weight, shape, insertion of umbilical cord, implantation site), endometriosis, Assisted Reproductive Technologies, Apgar score are fascinating new proposal risk factors.

Conclusions

Old and new data are not enough robust to draw firm conclusions. Prospective and well-designed studies, based on a well agreed internationally retained placenta definition, are needed in order to clarify this potential dramatic and life-threatening condition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03721-9.

Retained placenta and postpartum hemorrhage: time is not everything

PURPOSE

Postpartum hemorrhage is the major cause of maternal mortality worldwide. Retained placenta accounts for nearly 20% of severe cases. We investigated the influence of the time factor and retained placenta etiology on postpartum hemorrhage dynamics.

METHODS

Our retrospective study analyzed a single-center cohort of 296 women with retained placenta. Blood loss was measured using a validated and accurate technique based on calibrated blood collection bags, backed by the post- vs pre-partum decrease in hemoglobin. We evaluated the relationship between these two blood loss parameters and the duration of the third stage of labor using Spearman rank correlation, followed by subgroup analysis stratified by third stage duration and retained placenta etiology.

RESULTS

Correlation analysis revealed no association between third stage duration and measured blood loss or decrease in hemoglobin. A shorter third stage (< 60 min) was associated with significantly increased uterine atony (p = 0.001) and need for blood transfusion (p = 0.006). Uterine atony was significantly associated with greater decrease in hemoglobin (p < 0.001), higher measured blood loss (p < 0.001), postpartum hemorrhage (p = 0.048), and need for blood transfusion (p < 0.001).

CONCLUSION

Postpartum blood loss does not correlate with third stage duration in women with retained placenta. Our results suggest that there is neither a safe time window preceding postpartum hemorrhage, nor justification for an early cut-off for manual removal of the placenta. The prompt detection of uterine atony and immediate prerequisites for manual removal of the placenta are key factors in the management of postpartum hemorrhage.

Effect of antepartum vitamin D3 (cholecalciferol) and postpartum oral calcium administration on serum total calcium concentration in Holstein cows fed an acidogenic diet in late gestation

Several strategies are available to control periparturient hypocalcaemia in dairy cows. Three complementary strategies were applied in this study: feeding a low DCAD (acidogenic) ration during late gestation, oral vitamin D₃ (cholecalciferol) administration in late gestation, and oral Ca administration immediately after parturition. Multiparous Holstein cows (n = 240) were fed an acidogenic ration in late gestation and randomly assigned to one of three treatment groups. Group A (n = 80) were fed the acidogenic diet without supplementary Ca or cholecalciferol. Group Ca + A (n = 80) received 50 g of Ca as an oral bolus at calving and 12 h later. Group D₃ + Ca + A (n = 80) were administered 3 mg of cholecalciferol orally each day starting 3 to 5 days before the anticipated calving date and 50 g of Ca as an oral bolus at calving and 12 h later. Blood and urine samples were obtained periodically from a random subset of 20 cows in each group from day 5 antepartum to day 21 postpartum and selected analytes measured. Data was analyzed using mixed models analysis. Serum Ca concentrations in group D₃ + Ca + A were higher 12 h before and at parturition, compared to the two other groups. Oral Ca administration transiently increased mean serum Ca concentrations at 6 h after treatment initiation in groups D₃ + Ca + A and Ca + A. We conclude that daily oral administration of 3 mg of cholecalciferol for up to 5 days before calving, combined with feeding an acidogenic ration in late gestation and oral Ca immediately after parturition, provided the highest periparturient serum Ca concentrations.

Association of postpartum uterine diseases with lying time and metabolic profiles of multiparous Holstein dairy cows in the transition period

The objective of this study was to assess how uterine disorders alter the lying behaviour and plasma biomarkers in dairy cows. 34 multiparous cows were retrospectively classified into three groups according to the first uterine disorder that cows were diagnosed with: retained placenta (RP), metritis (MET), or healthy (H; cows without any clinical disease). Lying time (LT) and duration of lying bouts (LB) were monitored between 6 weeks prior to and 8 weeks after calving via the AfiAct II pedometer. Blood samples were collected routinely between 14 days before and 28 days after calving. Data was analysed using Proc MIXED of SAS ver. 9.4. Regardless of grouping, both LT and LB were longer (P < 0.01) in the prepartum period (774 ± 16.6 min/day and 89.9 ± 2.1 min/bout) than in the first 28 days after calving (DFC; 653 ± 16.7 min/day and 63.7 ± 2.1 min/bout). Cows with RP had longer LT than healthy cows during the last 3 weeks before calving (837 ± 30.9 vs. 735 ± 27.1 min/day; P < 0.05). LT in cows with MET and healthy cows were not significantly different. The LB was similar among groups, averaging 76.1 ± 3.4 min/bout in healthy cows, 73.2 ± 3.8 min/bout in cows with RP, and 75.2 ± 3.7 min/bout in cows with MET (P > 0.05). Compared with healthy cows, cows with RP laid down longer and stood up for shorter times (P < 0.05), particularly before calving. In addition, cows with RP had increased mobilization of body stores and more pronounced inflammatory status, as demonstrated by plasma haptoglobin (P = 0.04) and albumin (P < 0.01) concentrations. Our data suggest that automatic monitoring of lying behaviour could help identify cows at increased risk of developing certain disorders, such as RP.

Blood urea nitrogen may serve as a predictive indicator of retained placenta in dairy cows

Retained placentae (RP) results in significant economic losses to dairy farmers. In Experiment 1, to screen biochemical indicators of RP, 21 cows with RP and 21 cows with no retained placenta (NRP) were selected as a control group, and blood was collected at -7 d, 0 h (parturition) and 12 h. Serum biochemical indicators were ascertained. Results indicate serum concentrations of phosphorus (P) and blood urea nitrogen (BUN) in cows of the RP group were markedly greater than in cows of the NRP group at -7 d (P < 0.01). In Experiment 2, to evaluate predictive indicators for RP, 34 cows with RP and 34 cows with NRP were selected, and there was blood sampling at -15 d, -10 d, -7 d, -4 d, and -1 d. Serum P, BUN, and total protein (TP) were evaluated. Associations of values among the three indicators and occurrence of RP were analyzed using binary logistic regression. Results indicate there was a negative correlation between only the values for BUN and RP (P = 0.016). In Experiment 3, to test hypothesis that relatively greater concentrations of BUN effects immune function in placental tissues, four cows were selected, placentae were collected at 0 and 12 h, and hematoxylin-eosin (HE) staining was performed. Results indicated that the extent of inflammatory cell infiltration and vascular proliferation were less at the 12 than 0-hour timepoint. Taken together, BUN at -7 d may serve as a predictive indicator of RP in cows.

The comparison of protein map between retained and released bovine placenta

Placental retention in cows may be the result of altered protein pattern in comparison to physiologically released fetal membranes. Aim of study was to separate and identify proteins from maternal and fetal part of placenta and to compare them between released and retained fetal membranes. Six not retained and 6 retained tissues were obtained from healthy cows during routinely performed caesarian section. Cows were allocated to appropriate groups retrospectively. Samples were homogenized in phosphate buffer and subjected to 2D electrophoresis. After analysis of gels selected spots were excised and proteins were identified by MS. Two-dimensional electrophoresis detected and identified 886 spots in examined tissues. Significant differences (p < .05) were noticed between appropriate parts of retained and released placenta. In maternal part of retained placenta 40 spots showed lower abundance and 47 higher abundance in comparison to healthy samples. While in fetal part of retained placenta respective values were 60 and 125 proteins. Out of 73 identified proteins, 26 were significantly different between respective maternal (19) and fetal (7) part of retained and released placenta. In summary, protein profile of released and retained placenta express the presence and abundance of different proteins. It may suggest that selected proteins could be target molecules in searching for reasons for placental retention. Further identification of spots obtained here may provide with more detailed explanation of mechanisms of placental retention.

Intra-umbilical vein injection of carbetocin versus oxytocin in the management of retained placenta

INTRODUCTION

Retained placenta can be defined as lack of expulsion of the placenta within 30 min of delivery of the infant. It is a significant cause of maternal mortality and morbidity throughout the developing world.

AIM OF THE WORK

The aim of this study was to compare the efficacy of intra-umbilical vein injection of carbetocin versus oxytocin in the management of retained placenta.

PATIENTS AND METHODS

A total of 200 women were included in this study. They were divided into two groups; each 100 women. The first group received intra-umbilical vein injection of 1 mL carbetocin (containing 100 μg carbetocin) diluted in 20 mL normal saline 0.9% and the second group received intra-umbilical vein injection of 20 IU oxytocin diluted in 20 mL normal saline 0.9%.

RESULTS

Total blood loss (ml) and duration of the third stage of labor (minutes) were significantly lower in carbetocin group when compared to oxytocin group. Postoperative Hb concentration (g/dl) was significantly higher in carbetocin group. Also there was a highly significant difference between both groups as regard change in Hb concentration (g/dl) with less change in the carbetocin group. The need for additional uterotonic drugs following placental delivery and the occurrence of postpartum hemorrhage and the need for blood transfusion were significantly lower in the carbetocin group.

CONCLUSION

Intra-umbilical carbetocin is more effective than intra-umbilical oytocin as a method for management of retained placenta. Intra-umbilical carbetocin seems to have more acceptable hemodynamic safety profile when compared to intra-umbilical oxytocin in the management of retained placenta.

Risk factors, early and late postpartum complications of retained placenta: A case control study

OBJECTIVES

To identify risk factors and complications associated with 3^rd stage of labor removal of placental fragments (3^rd SRPF) by manual uterine revision under a strict protocol.

STUDY DESIGN

Ten years retrospective register-based cohort study of vaginal deliveries. Women with 3^rd SRPF n = 3297 (exposed) and those without n = 97,888 (non exposed) were compared.

MAIN OUTCOMES MEASURES

(1) risk factors for 3^rd SRPF aOR (95%CI) (2) early (2a) and late (2b) maternal complications.

RESULTS

(1) Risk factors for 3^rd SRPF procedure were assisted reproductive technologies 2.20 (1.73-2.34), preterm delivery 2.53 (2.21-2.88), preeclampsia 1.66 (1.25-2.21) Multiple previous early pregnancy loss (>3) 1.40(1.19-1.66), VBAC 1.26(1.13-1.47) and epidural analgesia 1.56 (1.46-1.69). (2a) Early complications: puerperal fever 1.1% vs 0.3%, blood transfusion 9.0% vs. 0.5%, prolonged maternal hospitalization 21.0% vs. 11.4%, all P < 0.0001. Puerperal readmission was 0.819% in the 3^rd SRPF vs. 0.315% the control group, P < 0.0001. (2b) Late complications: retained placenta and hysteroscopy / D&C rates were significantly higher among the 3^rd SRPF vs. controls: 40.7% vs. 7.1%, 14.8% vs. 3.6% and 48.1% vs. 18.2%, respectively, all P < 0.0001.

CONCLUSION

Uterine revision for 3^rd SPRF is associated with significant early and late maternal morbidity; should be considered discriminative of a population at risk and postpartum health care planning, beyond being a therapeutic intervention.

The increasing role of a retained placenta in postpartum blood loss: a cohort study

PURPOSE

To describe the association between quantity of blood loss, duration of the third stage of labour, retained placenta and other risk factors, and to describe the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage.

METHODS

Cohort study of all vaginal deliveries at two Danish maternity units between 1 January 2009 and 31 December 2013 (n = 43,357), univariate and multivariate linear regression statistical analyses.

RESULTS

A retained placenta was shown to be a strong predictor of quantity of blood loss and duration of the third stage of labour a weak predictor of quantity of blood loss. The predictive power of the third stage of labour was further reduced in the multivariate analysis when including retained placenta in the model. There was an increase in the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage, increasing from 12% in cases of blood loss ≥ 500 ml to 53% in cases of blood loss ≥ 2000 ml CONCLUSION: The predictive power of duration of the third stage of labour in regard to postpartum blood loss was diminished by the influence of a retained placenta. A retained placenta was, furthermore, present in the majority of most severe cases.

Management of the third stage of labor in second-trimester deliveries: How long is too long?

BACKGROUND

Retained placenta is the most common second-trimester delivery complication. As the optimal third stage of labor duration remains undefined, complications associated with retained placentas are difficult to study.

OBJECTIVE(S)

To determine the optimal third stage of labor duration in second-trimester deliveries based on estimates of time-specific probabilities of placental delivery, placental intervention, and postpartum complication.

STUDY DESIGN

We retrospectively studied adult women with singleton second-trimester vaginal deliveries. We identified third stage of labor duration, placental delivery method (spontaneous vs. manual/operative intervention), and indication for intervention. Postpartum complication was examined as a composite outcome. Differences among groups defined by delivery method and postpartum complication were tested using parametric and nonparametric tests. Probability curves describing the time-specific probabilities of placental delivery were derived using lifetable methods with group differences tested using the log-rank test. Probability of placental intervention and complication by time to placental delivery were examined using logistic regression with adjustment for confounders and other predictors.

RESULTS

We identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P < 0.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P < 0.01). At 2 h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2 h following fetal delivery. Patients with PPROM would require intervention by 34 min, and those with intrapartum fever or delivery EBL ≥500 mL would already exceed the risk threshold at fetal delivery.

CONCLUSIONS

Our study suggests that an optimal third stage of labor duration of approximately 2 h maximizes probability of spontaneous delivery and minimizes complication risk. Timing of intervention may be further individualized for patients based on maternal characteristics and intrapartum conditions.

Systematic review of prostaglandin analogues for retained placenta

BACKGROUND

Medical management of retained placenta could be a safe alternative to manual removal.

OBJECTIVE

To evaluate the efficacy of prostaglandin analogues for retained placenta.

SEARCH STRATEGY

MEDLINE, EMBASE, CENTRAL, ICTRP, LILACS, and OpenSIGLE were searched without language restrictions from inception to January 31, 2017, by combining terms for retained placenta and prostaglandin analogues.

SELECTION CRITERIA

Randomized controlled trials comparing prostaglandin analogues with any other intervention.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for inclusion, data extraction, and risk of bias. Data were extracted for meta-analyses. GRADE was used to evaluate the quality of data.

MAIN RESULTS

Seven randomized controlled trials (851 patients) were included. Prostaglandins did not increase the placenta expulsion rate (relative risk [RR] 1.40, 95% confidence interval [CI] 0.83-2.36) or decrease maternal transfusion (RR 0.72, 95% CI 0.43-1.22). In comparison with oxytocin, prostaglandins did not modify the expulsion rate (RR 1.26, 95% CI 0.90-1.78), maternal transfusion (RR 1.05, 95% CI 0.27-4.09), or time for delivery of placenta (mean difference -1.56 minutes, 95% CI, -9.25-6.13). Three trials comparing prostaglandins with oxytocin agonists, ergometrine, and manual removal reported similar results.

CONCLUSIONS

Prostaglandin analogues do not offer an effective alternative for management of retained placenta.

Failed manual removal of the placenta after vaginal delivery

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.

The effect of litter size, parity and farrowing duration on placenta expulsion and retention in sows

The hypothesis was that a prolonged parturition impairs placenta expulsion and can lead to retained placentas in sows. Furthermore, we hypothesized that application of oxytocin around the time of expulsion of the first placental part improves placenta expulsion. We recorded 142 parturitions of 101 Yorkshire x Large White sows. We determined parity, gestation length, number of liveborn and stillborn piglets, farrowing duration (time between first and last piglet) and the outcome variables: number of expelled placental parts, placenta expulsion duration (time between first and last placental part), first placental part expulsion (time between last piglet and first placental part) and last placental part expulsion (time between last piglet and last placental part). The relationship between farrowing duration and each of the outcome variables was investigated using four distinct multivariable models. Use of oxytocin (used in 44 out of 142 parturitions) increased number of expelled placental parts (3.8 ± 0.2 vs. 2.9 ± 0.3; P = 0.035), decreased the placenta expulsion duration (172 ± 44 vs. 328 ± 26 min; P = 0.011) and time of last placental part expulsion (148 ± 48 vs. 300 ± 24 min; P = 0.025). If oxytocin was not used, farrowing duration obeyed a quadratic relationship with the number of expelled placental parts (P = 0.001), placenta expulsion duration (P = 0.002) and time of last placental part expulsion (P = 0.024). If oxytocin was used, number of expelled placental parts was positively associated with number of liveborn piglets (β = 0.2 ± 0.1; P = 0.002) and affected by parity. 5th parity sows expelled more placental parts (4.3 ± 0.4) than 4th (3.2 ± 0.3; P = 0.024) and 3rd parity sows (2.7 ± 0.4; P = 0.008). Furthermore, placenta expulsion duration was positively associated with number of liveborn piglets (β = 18 ± 8 min; P = 0.025). First placental part expulsion was negatively correlated with farrowing duration (β = 0.3 ± 0.1; P = 0.001). Sows that experienced total (no expulsion of placental parts; n = 4) and partial retained placentas (no expulsion of placental parts after birth of the last piglet; n = 4) had longer farrowing durations (1009 ± 275 and 734 ± 136 min) than sows with no retained placentas (369 ± 202 min; P = 0.021 and P = 0.004). The results show that a prolonged parturition impaired and oxytocin improved placenta expulsion in sows. Furthermore, retained placentas occurred in 3-6% of the sows and was correlated with a prolonged parturition.

Extracellular matrix proteins in healthy and retained placentas, comparing hemochorial and synepitheliochorial placentas

The placenta expresses structural and biologically active proteins. Their synthesis is mainly regulated by genomic or nongenomic signals and modulated by hormones. These protein profiles are altered during different stages of pregnancy. The biological properties of extracellular matrix (ECM) proteins were defined and described in a number of tissues including placenta. These properties enable them to be the main players in the processes of attachment or invasion into the endometrium during initial placenta formation and its timely separation after delivery and detachment. In this review, we focused on the role of ECM proteins during attachment of the placenta to the uterine wall, its timely separation, and the implications of this process on retained or pathologically attached placenta. Although the amount of published information in this area is relatively scant, some of the key proteins and processes are well defined. We focused on the available data detailing the ECM protein profiles of human (histologically thin; hemochorial) and bovine (histologically thick; epitheliochorial) placentas and compared the shared and unique ECM proteins that are relevant to placental attachment and separation.

Oxidative stress and inflammation in retained placenta: a pilot study of protein and gene expression of GPX1 and NFκB

BACKGROUND

Retained placenta is associated with severe postpartum hemorrhage. Its etiology is unknown and its biochemistry has not been studied. We aimed to assess whether levels of the antioxidative enzyme Glutathione Peroxidase 1 (GPX1) and the transcription factor Nuclear Factor κβ (NFκβ), as markers of oxidative stress and inflammation, were affected in retained placentas compared to spontaneously released placentas from otherwise normal full term pregnancies.

METHODS

In a pilot study we assessed concentrations of GPX1 by ELISA and gene (mRNA) expression of GPX1, NFκβ and its inhibitor Iκβα, by quantitative real-time-PCR in periumbilical and peripheral samples from retained (n = 29) and non-retained (n = 31) placental tissue.

RESULTS

Median periumbilical GPX1 concentrations were 13.32 ng/ml in retained placentas and 17.96 ng/ml in non-retained placentas (p = 0.22), peripheral concentrations were 13.27 ng/ml and 19.09 ng/ml (p = 0.08). Retained placental tissue was more likely to have a low GPX1 protein concentration (OR 3.82, p = 0.02 for periumbilical and OR 3.95, p = 0.02 for peripheral samples). Median periumbilical GPX1 gene expressions were 1.13 for retained placentas and 0.88 for non-retained placentas (p = 0.08), peripheral expression was 1.32 and 1.18 (p = 0.46). Gene expressions of NFκβ and Iκβα were not significantly different between retained and non-retained placental tissue.

CONCLUSIONS

Women with retained placenta were more likely to have a low level of GPX1 protein concentration in placental tissue compared to women without retained placenta and retained placental tissue showed a tendency of lower median concentrations of GPX1 protein expression. This may indicate decreased antioxidative capacity as a component in this disorder but requires a larger sample to corroborate results.

Clinical and imaging predictors of management in retained products of conception

OBJECTIVES

To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC).

METHODS

334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis.

RESULTS

Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery.

CONCLUSIONS

Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial

OBJECTIVES

To compare between three different uterotonics (oxytocin, carbetocin and misoprostol) given via three different routes (intraumbilical, intravenous and sublingual, respectively) in reducing the need for manual removal of placenta (MROP).

METHODS

A randomized trial for cases with retained placenta 30 min following vaginal delivery. They received intraumbilical oxytocin, intravenous carbetocin or sublingual misoprostol. Main outcome measures were delivery of the placenta within 30 min following drug administration, and need for MROP. Secondary outcome measures were injection to placental delivery time, post-delivery hemoglobin, need for blood transfusion or additional uterotonics.

RESULTS

The overall success rate was 66.7% (64/96), 71.3% (67/94) and 63.7% (58/91) for oxytocin, carbetocin and misoprostol groups, respectively (p > 0.05). When time needed to achieve placental delivery considered, a significant difference was observed with the shortest time for carbetocin (16.61 ± 3.76 min), then oxytocin (18.28 ± 3.34 min) and lastly misoprostol (23.00 ± 3.38 min) (p <0.001). Again, carbetocin group needed less additional uterotonics to achieve adequate uterine contractions (p <0.001).

CONCLUSIONS

Although we aimed to exploit the advantage of certain drug over another, all seemed to have close efficacy but it would be important that further research should highlight availability, cost, ease of administration and storage requirements to determine which agent would best be used in this clinical scenario.

Occurrence of retained placenta is preceded by an inflammatory state and alterations of energy metabolism in transition dairy cows

Background

Failure to expel fetal membranes within 24 h of calving is a pathological condition defined as retained placenta (RP). The objective of this investigation was to evaluate whether there are alterations in several selected serum variables related to innate immunity and carbohydrate and lipid metabolism that precede occurrence of RP in transition Holstein dairy cows.

Methods

One hundred multiparous Holstein dairy cows were involved in the study. Blood samples were collected from the coccygeal vein during the −8 to +4 wks around parturition, once per week before the morning feeding. Six healthy control cows (CON) and 6 cows with RP were selected and serum samples at −8, −4, time of diagnosis of disease, and +4 wks relative to parturition were used for analyses. All samples were analyzed for lactate, non-esterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor (TNF), haptoglobin (Hp), and serum amyloid A (SAA).

Results

Cows with RP had greater concentrations of serum lactate, IL-1, IL-6, TNF, and SAA in comparison with CON cows. Intriguingly, elevated concentrations of all five variables were observed at −8 and −4 wks before the occurrence of RP compared to healthy cows. Cows with RP also had lower DMI and milk production vs CON animals; however milk composition was not affected by RP.

Conclusions

Cows with RP showed an activated innate immunity 8 wks prior to diagnosis of disease. Overall results suggest that serum IL-1, IL- 6, and TNF, and lactate can be used as screening biomarkers to indicate cows that might have health issues during the transition period.

Retained placenta: will medical treatment ever be possible?

The standard treatment for retained placenta is manual removal whatever its subtype (adherens, trapped or partial accreta). Although medical treatment should reduce the risk of anesthetic and surgical complications, they have not been found to be effective. This may be due to the contrasting uterotonic needs of the different underlying pathologies. In placenta adherens, oxytocics have been used to contract the retro‐placental myometrium. However, if injected locally through the umbilical vein, they bypass the myometrium and perfuse directly into the venous system. Intravenous injection is an alternative but exacerbates a trapped placenta. Conversely, for trapped placentas, a relaxant could help by resolving cervical constriction, but would worsen the situation for placenta adherens. This confusion over medical treatment will continue unless we can find a way to diagnose the underlying pathology. This will allow us to stop treating the retained placenta as a single entity and to deliver targeted treatments.

Differences in extracellular matrix remodeling in the placenta of mares that retain fetal membranes and mares that deliver fetal membranes physiologically

INTRODUCTION

In mammals, placenta separation at term may involve degradation of the extracellular matrix by matrix metalloproteinases (MMPs). The activity of MMPs is modulated by TIMPs. We hypothesized that the placentas of mares that deliver fetal membranes physiologically and those that retain fetal membranes (FMR) differ in terms of histology; mRNA expression of MMP-2 and MMP-9; protein expression of MMP-2, MMP-9, and TIMP-2; and the potential activity of both MMPs.

METHODS

Placenta biopsies were taken from mares (n = 9; 4 FMR, 5 controls) immediately after foal expulsion. Retention was defined as failure to expel all fetal membranes within 3 h of expulsion. All mares were monitored for time of expulsion. The degree of allantochorial/endometrial adhesion was determined in FMR mares, and biopsies from all mares were histologically examined. mRNA expression, protein immunolocalization, protein amount and potential enzyme activity were determined with RT-PCR, immunohistochemistry, Western Blotting and zymography, respectively.

RESULTS

FMR mares had strong to extremely strong allantochorial/endometrial adhesion, and significantly more connective tissue in the allantochorial villi than controls. The range of MMP-2 mRNA expression levels was more than 13 times greater in FMR mares than in controls. Protein content of both MMPs and TIMP-2 differed significantly between groups. The range of potential MMP-2 and MMP-9 activity was larger in FMR mares, and MMP-2 potential activity was 1.4 times higher in controls (P = 0.02).

DISCUSSION

These results indicate differences in extracellular matrix remodeling in FMR mares and controls, and suggest dysregulation of MMP expression and activation in FMR mares.

Retained placenta: Do we have any option?

Retained placenta is a known cause of post-partum haemorrhage and maternal mortality. A recent systemic review has confirmed that the incidence of retained placenta had increased all over the world, which is more common in developed countries. Failure of retro-placental myometrium contraction is the main cause of retained placenta. Maternal age greater than 35 years, grandmultipara, preterm labor, history of previous retained placenta, and caesarean section were the risk factors for retained placenta. Manual removal of the placenta has been the treatment of choice. Attempts had been made by clinician and researchers to find a safe, effective and reliable method to avoid the need for surgical intervention. The efficacy and safety of prostaglandin, nitroglycerin or acupuncture in the management of retained placenta are yet to be further evaluated. Nonetheless, till date only intra-umbilical vein oxytocin has been studied extensively but with varied success. More randomized clinical trials are needed to address this issue. However, if immediate manual placenta removal service is unavailable, a trial of intra-umbilical vein oxytocin 100 IU at a total volume of at least 40 mL while preparing for transfer to a tertiary center or theatre may result in spontaneous expulsion of the placenta.