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Objective: To assess the accuracy of diagnosing retained products of conception (RPOC) in symptomatic versus asymptomatic women, and to identify potential divergent ultrasound features between these groups., Methods: This retrospective study included women aged 17-50 years who underwent hysteroscopy for suspected RPOC during 2018-2021. Clinical and sonographic data were analyzed, and multivariable linear regression models employed, to examine correlations between RPOC and sonographic findings, and to compare diagnostic accuracy between symptomatic and asymptomatic women., Results: Of the 225 women included, 123 (54.7 %) were symptomatic and 102 (45.3 %) were asymptomatic. Hysteroscopy complications were more frequent in asymptomatic women. Regarding sonography, statistically significant differences were not found between the groups in endometrial thickness or uterine fluid presence, but positive Doppler flow was more common in asymptomatic than symptomatic women. Endometrial thickness >1.49 cm demonstrated diagnostic utility, with similar sensitivity and specificity in the two groups. Multivariable models revealed significant associations of RPOC presence with endometrial thickness and Doppler flow in symptomatic women. In both groups, hysteroscopy enhanced diagnostic accuracy, with higher positive predictive values and lower false-positive rates compared to ultrasound alone., Conclusion: An endometrial thickness cutoff of 1.49 cm aids diagnosing RPOC. Doppler flow enhances diagnostic value in symptomatic women. Integration of hysteroscopy improves diagnostic accuracy compared to ultrasound alone. Regular sonographic assessment for women with identifiable risk factors assists in RPOC detection irrespective of symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The complex etiopathology of retained placenta (RP) and hazards associated with it has made it crucial for researchers and clinical veterinarians to study pathogenesis, early-warning diagnosis, and treatment. This study aimed to screen the potential prognostic markers of RP in dairy cows using plasma metabolomics coupled with clinical laboratory indicators. Blood samples were collected from 260 dairy cows at 21, 14, 7, and 0 days before parturition and 7, 14, and 21 days after parturition. Consequently, 10 healthy cows and 10 cows with RP with similar parity, body condition score, and age were included in the study. The changes in clinical laboratory indicators of the enrolled cows from 21 before parturition to 21 days after parturition were assessed. After initial overview of the multivariate statistical data using PCA analysis, the data were subjected to orthogonal partial least-squares discriminant analysis. Compared with cows with RP at 7 days before parturition, the levels of endothelin and 6-keto-prostaglandin F1α were increased in healthy cows, while the level of estradiol and progesterone decreased. Adenine dinucleotide phosphate, hypoxanthine, guanine dinucleotide phosphate, inosine monophosphate, and L-arginine were revealed as potential prognostic markers of cows with RP at 7 days before parturition involved in the regulation of taste transduction, purine and glutathione metabolism, and autophagy. The best period for the early-warning diagnosis of RP in dairy cows is 7 days before parturition, and purine metabolism and autophagy may play a vital role in the occurrence and development of RP in dairy cows.

Introduction: Numerous studies have been performed assessing optimal treatment regimens for evacuating (retained) products of conception from the uterus, but standardized criteria for diagnosing retained products of conception (RPOC) are still lacking. We aim to provide an overview of diagnostic criteria in current literature, used to diagnose RPOC after induced first-trimester abortion or early pregnancy loss., Material and Methods: Pubmed, EMBASE, and the Cochrane library were searched systematically up until March 2020 for English articles reporting on induced abortion or early pregnancy loss. Articles not specifying diagnostic criteria used to assess completeness of treatment were excluded, as were conference abstracts, expert opinions, reviews, and case reports. Four elements of diagnostic criteria were described: diagnostic tools, parameters used within these tools, applied cut-off values, and timing of follow up. Additionally, a meta-analysis was performed assessing diagnostic qualities of the most often applied diagnostic tool and parameter., Results: The search strategy yielded 1233 unique articles, of which 248 were included, with a total of 339 517 participants. In the 79 included randomized controlled trials, six diagnostic tools to assess RPOC were identified, combined in 14 ways, with 55 different cut-off values. In 169 observational studies, seven diagnostic tools were identified, used in 28 combinations, applying 89 different cut-off values. Transvaginal ultrasonographic measurement of endometrial thickness with a cut-off value of at least 15 mm indicating RPOC, was used most frequently. In the timing of follow-up there was great variation, with 55 and 107 different combinations in randomized controlled trials and observational studies, respectively. Assessment of treatment success was scheduled most often around 2 weeks after treatment. Diagnostic qualities of endometrial thickness of 15 mm or more was not adequately assessed., Conclusions: There is wide variation in the way RPOC are assessed, and the criteria used to define RPOC following induced abortion and early pregnancy loss; ultrasonographic measurement of endometrial thickness, with a cut-off of 15 mm or more 2 weeks after primary treatment is the most widely used diagnostic approach. A meta-analysis on diagnostic accuracy of endometrial thickness of 15 mm or more did not lead to solid results. These findings can be a first step to develop a workable standard of establishing RPOC after induced abortion or early pregnancy loss., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To evaluate the impact of hysteroscopy for retained products of conception (RPOC) removal on surgical and reproductive outcomes., Data Sources: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, SciELO, EMBASE, and the Cochrane Central Register of Controlled Trials at the Cochrane Library) were searched from inception to March 2020., Methods of Study Selection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Medical Subject Headings terms and text words such as "retained products of conception," "placental remnants," "placenta," and "hysteroscopy" were used for the identification of relevant studies. We included observational and randomized studies that analyzed surgical and/or reproductive outcomes of women who underwent hysteroscopic removal of RPOC. The primary outcome was the complete resection rate after 1 procedure., Tabulation, Integration, and Results: Twenty out of 245 studies were applicable, with data provided for 2112 women. The pooled complete resection rate was 91% (95% confidence interval [CI], 0.83-0.96). The incomplete resection rate evaluated was 7% (95% CI, 0.03-0.14), with a complication rate of 2% (95% CI, 0.00-0.04). Out of 1478 procedures, only 12 cases (0.8%) of postsurgical intrauterine adhesions were reported. Regarding post-therapy fecundity, women attempting postoperative conception had a clinical pregnancy rate of 87% (95% CI, 0.75-0.95), with a live birth rate of 71% (95% CI, 0.60-0.81) and a pregnancy loss rate of 9% (95% CI, 0.06-0.12)., Conclusion: Hysteroscopy has a high rate of completely removing RPOC in a single surgical step, with low complication rates. Subsequent fecundity seems reassuring, with appropriate clinical pregnancy and live birth rates. However, standardization of approach and comparative trials of different hysteroscopic approaches are needed., (Copyright © 2020. Published by Elsevier Inc.)

Background: Retained products of conception (RPOC) refer to the presence of placental and/or fetal tissue in the uterus following delivery, miscarriage, or termination of pregnancy. The presence of such tissue might lead to complications, which might be the culprit of secondary infertility. Although some studies have considered the management of symptomatic RPOC, there are no data regarding the management of asymptomatic, incidentally diagnosed RPOC, nor the optimal time for surgical intervention required to prevent adverse reproductive outcomes., Objective: This study aimed to examine whether the time interval between the pregnancy termination to surgical evacuation of RPOC influences the reproductive outcome in asymptomatic women., Design: This is a retrospective cohort study, which includes women who were admitted for an elective procedure in the gynecology day-care clinic due to suspected RPOC. The diagnosis was made during patients' routine examination following either delivery or miscarriage between the years 2010 and 2018., Setting: Records of women who were admitted to the day-care gynecology department during the years 2010-2018 for hysteroscopic removal of RPOC., Patients: The patients were divided into three groups, according to the time from desired pregnancy to conception following the procedure (> 6; 3-6 and < 3 months). Data regarding obstetric history prior to the procedure was retrieved from patients' clinical files, while data concerning reproductive outcome following the procedure was obtained by telephone questionnaires., Intervention: Data regarding obstetric history prior to the procedure was retrieved from patients' clinical files, while data concerning reproductive outcome following the procedure was obtained by telephone questionnaires., Measurements: 75 patients whose reproductive outcome could be analyzed were included in the study. The time interval between the end of pregnancy and surgical intervention was analyzed as a continuous variable and was compared between the three groups, together with parameters such as age and obstetric history., Results: There were no significant differences between the groups., Conclusions: The main finding of the present study is that the time interval between the end of pregnancy and surgical evacuation of the asymptomatic, incidentally diagnosed RPOC, has no significant implication on patients' reproductive outcomes.

Introduction: Some studies have shown that women with a previous cesarean section, compared with women with a previous vaginal delivery, have an increased risk of retained placenta during a subsequent vaginal delivery. It is unknown whether this is mediated by anterior placental location, when the placenta might cover the uterine scar. The aim of this study was to evaluate whether the increased risk of retained placenta in women with a previous cesarean section is mediated by anterior placental location., Material and Methods: This is a population-based cohort study, with data from the regional population-based Stockholm-Gotland Obstetric Cohort, Sweden, from 2008 to 2014. The overall study population included 49 598 women with a vaginal second delivery, where adequate information about placental location from the second-trimester ultrasound scan was available. For the main analysis, including the 3921 women with a previous cesarean section, we calculated the relative risk of retained placenta in women with an anterior placental location, using women with non-anterior placental locations as reference. Relative risks were calculated as odds ratios (OR) with 95% CI. In a second model, adjustments were made for maternal age, height, country of birth, smoking in early pregnancy, infant sex, and in vitro fertilization., Results: In the overall study population, the rate of retained placenta at the second delivery was 2.0%. The proportion of women with a retained placenta was higher among women with a previous cesarean compared with those with a previous vaginal delivery (3.4% vs 1.9%; P < .0001). In the main analysis, including women with a previous cesarean section, the risk for retained placenta was not increased with anterior compared with non-anterior placental location (OR 0.84, 95% CI 0.60-1.20). Adjustments did not affect the estimates in a significant way., Conclusions: The increased risk of retained placenta in women with a previous cesarean section is not mediated by anterior placental location., (© 2020 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

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., Competing Interests: Declaration of Competing Interest We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled, “Blood urea nitrogen may serve as a predictive indicator of retained placenta in dairy cows”., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The aim of this study was to determine if reticulorumen ph, temperature and cow activity registered before calving can serve as indicators of diseases after calving.The cows were selected according to those fitting the profile of having had two or more lactations (on average 2.9±0.13 lactations), from 60 to 0 days before and the first 30 days after calving, and being clinically healthy. The clinical examination (identification of diseases after calving) was performed from 60 days before calving to 60 days after calving. Diseases after calving were diagnosed based on clinical symptoms specific to these diseases. The pH and temperature of the contents of the cow reticulorumens and cow activity were measured using specific smaX-tec boluses manufactured for animal care.We found that the highest pH and temperature before calving can serve as biomarkers of healthy cows after calving. The lowest reticulum temperature before calving can serve as an indicator of MF after calving. A positive correlation of reticulum pH and temperature before calving can serve as biomarkers of PR. Decreasing cow activity before calving can serve as an indicator of diseases after calving. For calving prognosis, temperature of the reticulorumen can be used; it decreased 6-7 days before calving., (Copyright© by the Polish Academy of Sciences.)

Rationale: Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta., Patient Concerns: A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta., Diagnoses: The patient was diagnosed with the infection, postpartum PE, and residual placenta., Interventions: The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy., Outcomes: The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy., Lessons: Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.

This study evaluated and compared infrared thermography (IRT) and rectal temperature (RT) as screening tests to identify sick transition dairy cows. Holstein cows (n = 72; 42 primiparous) had RT and IRT temperatures taken daily from 1 to 12 days in milk (DIM). Health examinations were performed daily to diagnose retained fetal membrane, milk fever and metritis, and blood was analyzed for β-hydroxybutyrate at 6 and 9 DIM to diagnose ketosis. Plasma concentrations of cortisol, interleukin-6, tumor necrosis factor α and serum amyloid A at 3, 6, 9 and 12 DIM were included as additional indicators of illness. Cows were categorized as true sick if clinically diagnosed with an illness, or if at least 2 blood parameters were above the normal range. Diagnostic test performances for RT and IRT variables were determined for each variable at a test referent value that provided the highest Youden's (J) index. The best performing screening test depended on the definition of true sickness. In general, the J index for RT was 0.15-0.17 whereas the highest J index for the IRT variables was 0.22 for the mean eye temperature and 0.19 for the mean cheek temperature. Infrared thermography was at least comparable to RT and some IRT variables performed better as a screening tests than RT. Future studies into the automation of IRT for surveillance of early postpartum diseases is warranted., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

A targeted quantitative metabolomics approach was used to study temporal changes of serum metabolites in cows that normally released their fetal membranes and those that retained the placenta. We identified and measured serum concentrations of 128 metabolites including amino acids, acylcarnitines, biogenic amines, glycerophospholipids, sphingolipids and hexose at -8 and -4 weeks before parturition, during the week of retained placenta (RP) diagnosis, and at +4 and +8 weeks after parturition. In addition, we aimed at identifying metabolite signatures of pre-RP in the serum that might be used as predictive biomarkers for risk of developing RP in dairy cows. Results revealed major alterations in the metabolite fingerprints of pre-RP cows starting as early as -8 weeks before parturition and continuing as far as +8 weeks after calving. Biomarker candidates found in this study are mainly biomarkers of inflammation which might not be specific to RP. Therefore, the relevance of serum Lys, Orn, acetylornithine, lysophophatidylcholine LysoPC a C28:0, Asp, Leu and Ile as potential serum biomarkers for prediction of risk of RP in dairy cows will have to be tested in the future. In addition, lower concentrations of LysoPCs, Trp, and higher kynurenine in the serum during prepartum and the week of occurrence of RP suggest involvement of inflammation in the pathobiology of RP.

Aim: To compare clinical variables, sonographic findings and pregnancy outcomes following the hysteroscopic removal of retained products of conception (RPOC) after delivery and abortion., Methods: This is a retrospective cohort of operative hysteroscopies performed between 2011 and 2015 for suspected RPOC, during which trophoblastic tissue was obtained. Patient demographics, clinical presentation, sonographic evaluation, subsequent infertility and pregnancy outcomes were compared between post-delivery (n = 85) and post-abortion (n = 93) cases., Results: The main presenting symptom in both study groups was vaginal bleeding. On sonographic evaluation, maximal endometrial thickness was significantly higher in the post-delivery group, while irregularity and increased flow were more common in the post-abortion group. There was a similar rate of deliveries following hysteroscopy in both groups with 40% in the post-delivery group and 39.7% in the post-abortion group. Deliveries in the post-delivery group were characterized by a higher rate of abnormal placentation - 30.5% - including low lying placenta and placenta accreta. A significant rate of vaginal deliveries in both groups entailed manual removal of the placenta or exploration of the uterine cavity (23.5 and 10.5%, p = 0.20)., Conclusion: Pregnancies following RPOC after delivery entail a higher rate of abnormal placentation., (© 2018 S. Karger AG, Basel.)

Study Objective: To compare the efficacy and reproductive outcomes of an ultrasound-guided manual vacuum aspiration (MVA) procedure with the widely accepted operative hysteroscopic (OH) procedure in the removal of retained products of conception (RPOCs) after normal vaginal delivery., Design: A retrospective cohort study (Canadian Task Force classification II-2)., Setting: A university-affiliated tertiary medical center., Patients: Eighty-six patients after normal vaginal delivery diagnosed with RPOCs from 2005 through 2015. This study was approved by the local institutional review board., Interventions: Treatment with either MVA or OH for patients diagnosed with RPOCs., Measurements and Main Results: Of 86 patients, 23 underwent remnant removal by ultrasound-guided MVA using a 6- to 7-mm catheter in a "see and treat" office procedure. Sixty-three patients underwent remnant removal using the OH procedure. Follow-up included sonographic examination 3 to 5 weeks after the procedure and long-term follow-up on complications and reproductive outcomes. Successful remnant evacuation and the overall complications rates were similar when comparing the MVA group and the OH group (95.7% vs 96.8% and 4.3% vs 4.7%, respectively). Conception rates and miscarriage rates were comparable in the MVA and OH groups (78.6% vs 72.2% and 9.1% vs 14.8%, respectively)., Conclusion: Preliminary results from 23 patients suggest that MVA is an efficient procedure with low complication rates and satisfactory reproductive outcomes. It does not require anesthesia or operating room facilities, allowing an immediate and inexpensive "see and treat" option for RPOCs. Further larger controlled trials are required., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Antenatal diagnosis of morbidly adherent placenta has been shown to improve outcomes, but existing predictors lack sensitivity. Our objective was to determine whether the presence of myometrial fibres attached to the placental basal plate (BPMYO) in an antecedent pregnancy is associated with subsequent morbidly adherent placenta., Design: A case-control study., Setting: Departments of Obstetrics and Gynecology and Pathology, Northwestern University, Chicago, IL, USA., Sample: Women who had at least two pregnancies with placental pathological evaluation., Methods: Cases were defined as women with evidence of morbidly adherent placenta (both clinically and pathologically) in their most recent pregnancy whereas women without evidence of morbidly adherent placenta served as controls. Pathological specimens of placentas from previous pregnancies were evaluated for BPMYO. The presence of BPMYO on a previous placenta was evaluated to determine whether it could be used to improve the antenatal diagnosis of morbidly adherent placenta., Results: Of the 25 cases of morbidly adherent placenta, 19 (76%) had BPMYO present on their previous placenta compared with 41 (41%) of controls (odds ratio 4.8, 95% CI 1.8-13.0). Adding BPMYO to a regression including other risk factors for morbidly adherent placenta (i.e. maternal age, number of previous caesarean sections, placenta praevia, previous multiple gestation, any previous curettage, and ultrasonographic suspicion of placenta accreta) significantly improved the sensitivity of antenatal diagnosis of morbidly adherent placenta (61% versus 39%, P < 0.001) without a change in specificity (97% versus 97%, P = 1.00)., Conclusion: BPMYO on previous placental pathology is associated with an increased risk of morbidly adherent placenta in a subsequent pregnancy. These findings may shed light on the pathophysiology of accreta and inform future research on predictors of accreta., Tweetable Abstract: Previous basal plate myometrium improves the ability to detect subsequent morbidly adherent placenta., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Study Objective: Removal of retained adherent placental remnants (RAPRs) may be challenging using traditional 5Fr or 7Fr hysteroscopic grasping forceps because they are very small. This is particularly true when the retained placental remnant is large. This video demonstrates the advantages of using the Hysteroscopy Endo-Operative System (HEOS), a specially designed operative hysteroscope with a 13Fr working channel, to remove retained placental remnants., Design: Step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III)., Setting: Third Xiangya Hospital of Central South University, Hunan, China., Patient: A 32-year-old woman was diagnosed with RAPRs 5 weeks after the evacuation of retained placenta after a spontaneous abortion at 16 weeks' gestation. Gynecologic examination revealed an anterior 8-week uterus and no tenderness. Serum β-human chorionic gonadotropin was 150 mIU/L. Sonography revealed an irregular intrauterine mass, 3.5 cm × 3.5 cm × 3 cm in size., Intervention: Removal of RAPRs using HEOS (Sopro-comeg Company, Bordeaux, France)., Measurement and Main Results: The operation time was only 12 minutes. The RAPRs were removed completely and quickly in 1 procedure with no complications. The serum β-human chorionic gonadotropin titer normalized 1 week after the procedure. This study was approved by the institutional review board of the Third Xiangya Hospital of Central South University., Conclusions: When indicated, removal of RAPRs using HEOS is safe and simple because of its large and strong cold forceps. Additionally, it avoids electrical and thermal injury to the endometrium, which is particularly important in a population that wants to preserve fertility., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

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., (© 2016 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: Recruiting and consenting women to peripartum trials can be challenging as the women concerned may be anxious, in pain, and exhausted; there may also be limited time for discussion and decision-making to occur. To address these potential difficulties, we undertook a qualitative evaluation of the internal pilot of a trial (Got-it) involving women who had a retained placenta (RP). We explored the experiences and views of women and staff about the information and consent pathway used within the pilot, in order to provide recommendations for use in future peripartum trials involving recruitment in emergency situations., Methods: In-depth interviews were undertaken with staff (n = 27) and participating women (n = 22). Interviews were analysed thematically. The accounts of women and staff were compared to identify differences and similarities in their views about recruitment and consent procedures., Results: Women and staff regarded recruitment as having been straightforward and facilitated by the use of simplified (verbal and written) summaries of trial information. Both parties, however, conveyed discordant views about whether fully informed consent had been obtained. These differences in perspectives appeared to arise from the different factors and considerations impinging on women and staff at the time of recruitment. While staff placed emphasis on promoting understanding in the emergency situation of RP by imparting information in clear and succinct ways, women highlighted the experiential realities of their pre- and post-birthing situations, and how these had led to quick decisions being made without full engagement with the potential risks of trial participation. To facilitate informed consent, women suggested that trial information should be given during the antenatal period, and, in doing so, articulated a rights-based discourse. Staff, however, voiced opposition to this approach by emphasising a duty of care to all pregnant women, and raising concerns about causing undue distress to the majority of individuals who would not subsequently develop a RP., Conclusions: By drawing upon the perspectives of women and staff involved in the same trial we have shown that they may operate within different experiential and ethical paradigms. In doing so, we argue for the potential benefits of drawing upon multiple perspectives when developing information and consent pathways used in future (peripartum) trials., Trial Registration: ISCRTN 88609453 .

Background: Hysteroscopic resection of retained products of conception has not been previously described to increase the risk for volume overload at the time of hysteroscopy., Case: A 35-year-old woman with a history of recurrent pregnancy loss was evaluated by a hysterosalpingogram that identified retained products of conception with adjacent contrast intravasation. She underwent a hysteroscopic resection of the uterine septum and products of conception. During the 15 minute operating time she developed a fluid deficit of 2,300 cc of 3% sorbitol with resulting hyponatremia despite normal pressure and flow settings on the fluid management equipment., Conclusion: When a hysterosalpingogram demonstrates likely retained products of conception with an accompanying intravasation of contrast media, the provider should consider this finding a potential risk factor for excess intravasation of hysteroscopic distention media and take additional precautions to avoid volume overload.

Objective: To assess the rate of complications of surgical interventions delayed more than 24 h after delivery in women suspected of placental remnants., Methods: A retrospective review was performed to analyse complications of delayed surgical interventions. Women were identified from the operation database and their medical records were reviewed to determine the rate of immediate and long-term complications, including reproductive outcome., Result: A total of 127 women were evaluated. The median interval between delivery and surgery was 42 days. Immediate complications were registered in 22.0% and re-interventions in 16.5%. Placental remnants were histologically confirmed in 63.8%. Intrauterine adhesions (IUAs), only of the severe type, were recorded in 20.5%, although a minority of women was hysteroscopically revised. The difference between women treated by dilatation and curettage (D&C) and hysteroscopy was not statistically significant. Similar reproductive outcomes were encountered in women treated by D&C and hysteroscopy and in women with and without IUAs, although the samples were small., Conclusion: Identification of placental remnants remains difficult while delayed interventions are associated with significant immediate and long-term complications. The impact on reproductive performance remains unclear. Further research is necessary to examine treatment options in relation to complications and reproductive outcome.

The aim of this study was to obtain the diagnostic and therapeutic approach among Swiss practitioners in cows with retained fetal membranes (RFM) (part 1). All members of the Association for ruminant health were contacted per email via the newsletter. The survey was completed by 128 veterinarians, partially responded by 140 veterinarians. The manual removal of the fetal membranes is practiced by 129 of the responding veterinarians. Cows with/without fever are treated usually with intrauterine antibiotics. Cows with RFM with/without fever are most commonly treated parenterally with tetracycline or penicillin. The use of cephalosporins and quinolones in cows with fever is more common than in cows without fever. With the present results of the survey veterinarians should critically question the supposed benefits of the manual removal of the placenta and the use of antibiotics in cows with RFM.

Measurement of serum haptoglobin (Hapto) concentrations results in only moderate reported specificity and sensitivity for the detection of metritic cows. The objective of this study was to evaluate associations between different variables and haptoglobin concentrations after calving. Parity, periparturient metabolic stress indicated by β-hydroxybutyric acid (BHBA) and nonesterified fatty acids (NEFA), calving difficulties, retained fetal membranes (RFM), and acute puerperal metritis (APM) were evaluated. A total of 443 Holstein Friesian cows were enrolled in this retrospective observational study. Acute puerperal metritis was diagnosed when a cow had fetid, reddish-brown, watery vaginal discharge in combination with rectal temperature ≥39.5°C. The retention of the fetal membranes has been defined as the failure to expel the fetal membranes within 12h after calving. Results of blood samples from 2 and 5 d in milk (DIM) were analyzed for Hapto, BHBA, and NEFA. Primiparous cows had a greater median Hapto concentration than multiparous cows at 5 DIM [primiparous: 2.25g/L, interquartile range (IQR) 1.45-2.50, n=146; multiparous: 1.13g/L, IQR 0.52-2.22, n=302; P<0.05]. Therefore, different Hapto thresholds based on references from literature for all cows (1.4g/L), primiparous cows (2.49g/L), and multiparous cows (1.4g/L) were used for further analysis. Periparturient metabolic stress indicated by elevated BHBA (≥1.2mmol/L) at 5 DIM was associated with elevated Hapto (odds ratio 2.39-2.87) regardless of parity. In contrast, elevated NEFA (≥0.6mmol/L) at 2 DIM was not a risk factor for elevated Hapto. Multiparous cows with assisted calving had a 2.46 times higher risk for elevated Hapto, whereas primiparous cows with assisted calving had no elevated risk for elevated Hapto at 5 DIM. Moreover, multiparous cows with RFM were 5.51 times more likely to have elevated Hapto at 5 DIM than cows without RFM. Acute puerperal metritis within the first 5 DIM was associated with elevated Hapto (odds ratio 2.74-5.01), regardless of parity. We speculate that the association of calving ease, RFM, and periparturient metabolic stress could explain the moderate sensitivity and specificity reported for the detection of metritic cows by measuring Hapto., (Copyright © 2015 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Regardless intensive research, the etiology and mechanisms of retention of fetal membranes in cows, still require elucidation. In our research approach, difference in gel electrophoresis (DIGE) and matrix-assisted laser desorption/ionization (MALDI) identification were used to obtain first results on protein profile of bovine placental membranes which were properly released or retained for more than 12 h after parturition., Methods: Placentomes from 6 cows that released placenta and from 6 cows that retained fetal membranes were homogenized, fluorescence labeled and subjected to DIGE., Results: Selected spots that significantly differed between retained and released placenta as well as spots with constant appearance were identified by MALDI. This allowed identification of the following proteins with high statistical reliability: Transforming growth factor beta 2 - high expression in maternal and fetal part of retained fetal membranes, Short transient receptor potential channel 5 -high expression in maternal part of retained and not retained fetal membranes, Rab GDP dissociation inhibitor beta - high expression in fetal part of retained and not retained fetal membranes, Proline dehydrogenase 2 - similar expression in all examined samples, Ras-related protein Rab-7b -high expression only in maternal part of not retained fetal membranes., Discussion: Up to now, these proteins have not been considered as possibly important molecules for the separation/retention of fetal membranes, but their biological roles may suggest it. Further studies are necessary to establish a full profile of bovine placental proteins and define target molecules that may be involved in separation/retention of fetal membranes., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To compare the reproductive outcomes of women with pathologically confirmed retained products of conception (RPOC) following spontaneous vaginal delivery versus first-trimester pregnancy termination., Methods: We retrospectively reviewed all cases of women who underwent uterine re-evacuation due to pathologically confirmed RPOC between January 1, 2000 and December 31, 2010. Reproductive outcomes were compared between women with RPOC following spontaneous vaginal delivery and those who underwent dilatation and curettage (D&C) due to first-trimester abortion., Results: The study group consisted of 176 patients with pathologically confirmed RPOC. Of those, 83 (47.1%) were admitted after spontaneous vaginal delivery and 93 (52.9%) following D&C due to first-trimester abortion. There were no significant differences in the conception rate, the mean time to conception and the rate of a new infertility problem between women with RPOC after vaginal delivery compared to those following pregnancy termination (p > 0.05). Furthermore, there were no significant differences between the groups in pregnancy outcomes following RPOC., Conclusion: Pathologically confirmed RPOC harbors the same reproductive outcomes following spontaneous vaginal delivery and first-trimester pregnancy termination., (© 2015 S. Karger AG, Basel.)

A case of prolonged retention in the uterus of placenta accreta after vaginal delivery is reported in the paper. The patient was 20 years old G3, P0 with two pregnancy terminations on request. She was admitted to the obstetric department of a regional hospital one day after the EDD with irregular contractions and non reassuring CTG. A few hours later intrauterine fetal demise occurred. Spontaneous labor commenced and a stillborn growth retarded fetus was delivered. Methergin was administered during the third stage of labor, but the placenta was not separated even after repeated Crede maneuvers, the last one under anesthesia. Since cervical spasm was present, the attempts for manual or instrumental separation of the placenta were unsuccessful. There was no genital bleeding, so further conservative approach was followed including continuous IV infusion of uterotonics, combined antibiotic therapy, close observation of the vital signs and the laboratory indicators. Three days after delivery the patient was transferred to a University Hospital because of subfebrile temperature. Her general condition on admission, although subfebrile, was good, there was no genital bleeding, the cervix was closed. The subfebrile temperatrure persisted despite antibiotic treatment; CRP was elevated (51,9 mg/l.). Because of suspicion for endomyometritis, on day 8th after delivery instrumental extraction of the placenta was undertaken with preparedness for hysterectomy in case of need. Although the procedure was difficult, with the placenta being extracted in parts, bleeding was scarce. The post operative period was uneventful and the patient was discharged from hospital five days after the intervention. A review of literature on the obstetric management of cases with retained placenta accreta after vaginal delivery is presented. The existing therapeutic options are discussed including their advantages and complications.

Placental polyp is the retained fragment of placental tissue after the parturition or abortion for indefinite period which forms a polypoidal mass in the uterus. It is predominantly composed of necrotic and hyalinized chorionic villi (ghost chorionic villi). We report a case of 26-year-old G2P2 woman presenting with vaginal bleeding. Her last pregnancy had occurred five years ago. Laboratory investigations revealed a positive urine pregnancy test and serum levels of beta-human chorionic gonadotrophin (β-hCG) was elevated. Ultrasonography revealed hyperechoic mass in uterine cavity. She underwent total abdominal hysterectomy and the pathological diagnosis was of a placental polyp.

The study objective was to improve ultrasonic diagnosis of retained placental tissue by measuring the volume of the uterine body and cavity using three-dimensional (3D) ultrasound. Twenty-five women who were to undergo surgical curettage due to suspected retained placental tissue were included. The volume of the uterine body and cavity was measured using the VOCAL imaging program. Twenty-one women had retained placental tissue histologically verified. Three of these had uterine volumes exceeding the largest volume observed in the normal puerperium. Seventeen of the 21 women had a uterine cavity volume exceeding the largest volume observed in the normal puerperium. In all 14 cases examined 28 days or more after delivery the cavity volume exceeded the largest volume observed in the normal puerperium. A large cavity volume estimated with 3D ultrasound is indicative of retained placental tissue. However, 3D ultrasound adds little or no diagnostic power compared to 2D ultrasound., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To assess the prediction and maternal morbidity of morbidly adherent placenta previa (PP) when currently available management options are used., Materials and Methods: This is a retrospective study of all women with PP/morbidly adherent placenta previa (MAPP) delivered at our hospital over a period of 9 years. Data were obtained through hospital registry and medical records search., Results: A total of 81 PP were identified, 23 (28.4%) of them had MAPP. All MAPP had previous lower segment cesarean section (LSCS). The following are associated with increased odds of MAPP versus PP, LSCS (OR for each additional LSCS was 2.9 (95% confidence interval: 1.8, 4.5, p ≤ 0.005), age ≥35 years (OR 4.3 (95% CI: 1.4, 12.7, p = 0.008). Anterior or central placenta (OR = 11.6; p = 0.028). Women with previous PP were at risk. Fifteen women were diagnosed by ultrasound [sensitivity 0.65 (0.43, 0.83) and PPV 0.79 (0.54, 0.93)]. MAPP was associated with risk of massive transfusion, bladder injury, DIC and admission to intensive care unit (ICU) (p < 0.005, 0.008, 0.036 and 0.008, respectively). One maternal death was reported in the MAPP group., Conclusion: MAPP is associated with high morbidity and mortality. As the diagnosis is often not certain before delivery, we recommend that all PP and previous LSCS are assumed to be morbidly adherent, and should be managed in properly equipped centers.

Background: Removal of retained placental tissue postpartum and retained products of conception (RPOC) abortion is done by uterine curettage or hysteroscopy. Trauma to the endometrium from surgical procedures, primarily curettage, can cause intrauterine adhesions (Asherman's syndrome) and subsequent infertility. The incidence of malpractice claims relating to intrauterine adhesions is rising, justifying reevaluation of the optimal way of handling these complications., Objectives: To review malpractice claims regarding intrauterine adhesions, and to explore the clinical approach that might reduce those claims or improve their medical and legal outcomes., Methods: We examined 42 Asherman's syndrome claims handled by MCI, the largest professional liability insurer in Israel. The clinical chart of each case was reviewed and analyzed by the event preceding the adhesion formations, timing and mode of diagnosis, and outcome. We also assessed whether the adverse outcome was caused by substandard care and it it could have been avoided by different clinical practice. The legal outcome was also evaluated., Results: Forty-seven percent of the cases occurred following vaginal delivery, 19% followed cesarean section, 28% were RPOC following a first-trimester pregnancy termination, and 2% followed a second-trimester pregnancy termination., Conclusions: It is apparent that due to the lack of an accepted management protocol for cases of RPOC, it is difficult to legally defend those cases when the complication of Asherman syndrome develops.

Dairy cows often experience decreased immune function around the time of calving, typified by impaired polymorphonuclear neutrophil (PMN) function and a transient neutropenia. This is associated with increased disease incidence, including mastitis, retained placenta, and metritis. In an attempt to improve PMN functional capacity during the periparturient period, we injected cows with recombinant bovine granulocyte colony-stimulating factor covalently bound to polyethylene glycol (PEG rbG-CSF) twice subcutaneously, about 6d before calving and within 24h after calving. Twenty-one cows in their second pregnancy were enrolled in this study and divided into 2 groups: PEG rbG-CSF treated (n=11) and saline-treated controls (n=10). The PMN numbers quickly and dramatically increased after PEG rbG-CSF administration and remained elevated through the end of the experiment (13d after calving). Exocytosis of myeloperoxidase by stimulated PMN, which is generally decreased in periparturient cows, was markedly increased by PEG rbG-CSF after injection. Higher myeloperoxidase exocytosis persisted for at least 10d after calving. The PMN superoxide anion release and phagocytosis activity did not differ between groups. Injection of PEG rbG-CSF was safe for cows, with no significant negative effects observed. The greatest single effect of PEG rbG-CSF administration was a dramatic increase in circulating numbers of PMN. The increased numbers of PMN ready to move to a site of infection early in the course of an infection may improve the ability of the cow to ward off clinical disease in the periparturient period., (Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the clinical situations that leads us to carry out curettage after cesarean section, the ultrasound prior surgery, intraoperative, and pathological findings., Methods: A retrospective study of all cases of postpartum curettage after cesarean section in a level 3 maternity unit., Results: There were 42 curettages to women with cesarean sections (1.6% of all cesarean sections). The indications for curettage were: fever: 21, methrorraghia: 11, and residual trophoblastic tissue: 10. In the previous ultrasound, all indicated curettages for retained trophoblastic tissue showed it, and in a lower proportion those indicated for fever (66.6%) or methrorraghia (22.2%). A total of fourteen curettages (35%) were performed without suspect image of retained tissue, and in all cases the surgeon described to obtain small amount of tissue. From material submitted to pathologic evaluation trophoblastic tissue was found in 64.7%, and there were no differences as curettage indication., Conclusions: When the previous ultrasound do not showed retained tissue, the surgeon did not remove retained material. When extracted there were always in small amounts. Therefore, it could be concluded that after cesarean section the curettage should be indicated only in the presence of evident ultrasound image of retained products.

Amniotic fluid embolism (AFE) is a rare, but often catastrophic, complication of pregnancy and associated with severe coagulopathy. We present an algorithm-based approach in managing coagulopathy and hemorrhage in a fatal case of histopathologically proven AFE. Thrombelastometry was used for rapid evaluation of the coagulation status. Stop of extensive hyperfibrinolysis with tranexamic acid, stabilization of initial clot formation with high-dose fibrinogen and platelet transfusions, and use of prothrombin complex concentrate together with a 1: 1 transfusion regimen of red packed cells and fresh frozen plasma was successful to control diffuse bleeding and restore clot firmness after hysterectomy. Stable clotting situation was maintained despite further clinical deterioration and development of multiple organ failure in this patient.

A first trimester miscarriage is most often painfully experienced by the patients. The practitioner should be able to offer appropriate, timely, efficient and safe medical management, allowing a shorter convalescence without effect on subsequent fertility. Each step of the process of the miscarriage results in clinical and ultrasonographic characteristics, and requires a specific therapeutic strategy. Vaginal ultrasound allows confirmation of early pregnancy failure (missed miscarriage) diagnosis and to estimate the complete or incomplete removal of trophoblastic material. However, the endometrial thickness does not appear to be predictive for the risk of persistent bleeding or secondary surgery. Surgical evacuation of the product of conception remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment with misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) do not increase the risk of complications, particularly the infectious one. However, these alternatives generally require more prolonged outpatient follow-up leading to more frequent consultations and surgical emergencies.

The incidence and importance of retained placenta (RP) varies greatly around the world. In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate. In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely associated with mortality. There are three main types of retained placenta following the vagina delivery: placenta adherens (when there is failed contraction of the myometrium behind the placenta), trapped placenta (a detached placenta trapped behind a closed cervix) and partial accreta (when there is a small area of accreta preventing detachment). All can be treated by manual removal of placenta, which should be carried out at 30-60 minutes postpartum. Medical management is also an option for placenta adherens and trapped placenta. The need for manual removal can be reduced by 20% by the use of intraumbilical oxytocin (30 i.u. in 30 mL saline). A trapped placenta may respond to glyceryl trinitrate (500 mcg sublingually) or gentle, persistent, controlled cord traction.

The objectives of this study were to determine the non-specific aerobic and anaerobic bacterial causes of endometritis causing repeat breeding of cycling Iraqi buffalo cows at Nineveh province, validate diagnostic criteria for endometritis and to evaluate the treatment efficiency of using systemic or intra-uterine infusion of antibiotics for the treatment of endometritis. Data were collected from 60 buffalo cows with history of repeat breeding in different herds. All buffaloes were subjected to detailed clinical examination including external inspection, vaginoscopy and transrectal palpation of the cervix, uterus and ovaries. Swabs for bacteriology and biopsies for histopathology were collected from the uterine lumen from each cow. Character, odour and estimation of polymorphonuclear cells (PMN) of the vaginal mucus were scored. Blood samples were collected from cows for creatine kinase (CK) and aspartate aminotransferase (AST) measurement. Treatment conducted using oxytetracycline with tylosin in local intrauterine infusion or systemically with hormonal treatment. The most pre-disposing factor for uterine infection was retained placenta (13.3%). The most prevalent bacteria in uterine lumen were E. coli (23%), Archanobacterium pyogenes (13%) and Staphylococcus aureus (10%) were mostly isolated from buffaloes with repeat breeding. Vaginal mucus character score was associated with the bacterial growth density score. The difference in PMN was highly significant (p < 0.01) in animals with repeat breeding than control groups. In addition, PMNs was significantly (p < 0.01) correlated r = 0.894 with the character of vaginal discharge. High level of PMNs observed in buffaloes infected with A. pyogenes. Buffalo cows with endometritis had higher CK (321.47 +/- 39.06 vs 162.01 +/- 16.41 U/l) and AST (133.93 +/- 12.43 vs 97.01 +/- 6.86 U/l) activities (p < 0.05) than control-heifers, but no significant difference was observed between buffalo cows with endometritis in CK (321.47 +/- 39.06 vs 208.33 +/- 5.84) and AST (133.93 +/- 12.43 vs 156.17 +/- 9.65) activities than control-pluriparious. It could be concluded that A. pyogenes was the only non-specific uterine pathogen directly associated with severe endometrial lesions. Vaginoscopy examination combined with palpation of uterus increase the accuracy of diagnosing endometritis and cytogenic examination of uterine discharge is more reliable method of establishing the presence or absence of uterine inflammation in buffalo cows. Animals with repeat breeding (endometritis) showed clinical cure and improved pregnancy in all treatment groups with no significant difference. The use of oestradiol in repeat breeder cases has no effect in improving neither clinical cure rate nor pregnancy rate.

Objective: To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage., Methods: This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed., Results: Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups., Conclusion: The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

Introduction: This study aimed to determine the incidence of, and identify independent risk factors to retained placenta in Ile-Ife, southwestern Nigeria., Methods: This was a prospective case-control study involving 120 women with retained placenta after vaginal birth at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, southwestern Nigeria over a period of seven years. Two consecutive normal deliveries after each retained placenta served as controls. Following a bivariate analysis, a multivariate logistic regression model was constructed in order to define independent risk factors for retained placenta while controlling for confounding variables., Results: During the study period, there were 120 cases of retained placenta, and the total number of deliveries was 6,160, making the incidence 1.9 percent. Independent risk factors associated with retained placenta include non-use of antenatal care (odds-ratio [OR] 22.71, 95 percent confidence interval [CI] 10.5-49.12, p-value is less than 0.000), previous retained placenta (OR 15.22, 95 percent CI 3.30-70.19, p-value is less than 0.000), previous caesarean section (OR 12.00, 95 percent CI 2.05-70.19, p-value is less than 0.006), maternal age 35 years or more (OR 7.10, 95 percent CI 1.5-32.40, p-values is less than 0.012), grand multiparity (OR 6.63, 95 percent CI 1.88-23.40, p-value is less than 0.003), previous dilatation and curettage (OR 4.44, 95 percent CI 1.69-11.63, p-value is less than 0.002), preterm delivery (OR 3.12, 95 percent CI 1.12-8.68, p-value is less than 0.029) and placenta weight less than 501 g (OR 2.91, 95 percent CI 1.34-6.32, p-value is less than 0.007)., Conclusion: Women with identifiable risk factors should be targeted for the prevention of retained placenta. There is a need for the training of birth attendants in the proper conduct of delivery and third stage of labour to prevent placenta retention and postpartum haemorrhage.

The objective of this study was to compare 2 strategies for the management of dairy cows having retained fetal membranes (RFM) with regard to clinical traits, milk yield, and reproductive performance. In contrast to recent studies evaluating optimal strategies for the management of cows with RFM, this trial was conducted on small dairy farms with 26 to 166 cows per herd. In the systemic (SYS) group (n = 116), cows having RFM and a rectal temperature > or = 39.5 degrees C were treated with 1 mg/kg of body weight of ceftiofur on 3 to 5 consecutive days. The RFM cows without fever remained untreated. In the intrauterine (IUT) group (n = 115), all RFM cows received an intrauterine treatment with 6 g of tetracycline on 3 consecutive days combined with an attempt to remove the fetal membranes manually. The IUT cows with a fever received an additional systemic treatment with 10 mg/kg of body weight of amoxicillin on 3 to 5 consecutive days. Body temperature, daily milk yield, prevalence of vaginal discharge 28 to 35 d in milk (DIM), and reproductive performance traits within 200 DIM were monitored. The proportion of cows experiencing fever within 5 d after enrollment was greater in SYS compared with IUT. The proportion of cows with mucopurulent or purulent vaginal discharge 28 to 34 DIM did not differ between the groups. Furthermore, no significant differences between groups were found in daily milk yield in the first 10 d after enrollment, or in reproductive performance or proportion of cows culled. Significant differences in the proportion of cows with a fever in SYS and IUT have not been reported in studies with similar study designs conducted on large dairy farms. Further results on milk yield and reproductive performance, however, support findings that a management strategy for RFM based on a selective systemic treatment of feverish cows is at least as efficacious as a strategy based on intrauterine treatments of all cows and a systemic antibiotic treatment of feverish cows.

In a world bewildered by spectacular advances in imaging technology, the early detection of an abdominal pregnancy should be a feasible objective. A case of an advanced abdominal pregnancy is presented. Although the pregnancy was the result of in vitro fertilisation technology, the diagnosis was not suspected until 35 weeks gestation. Both ultrasound and magnetic resonance imaging (MRI) were used to achieve a diagnosis prior to delivery. The placenta was left within the peritoneal cavity but removal was necessitated for maternal symptomatology 4 months postdelivery. This case illustrates that despite the almost ubiquitous usage of prenatal ultrasound, extrauterine pregnancies may not be detected in a timely manner unless attention to basic ultrasound techniques is followed.

Four at-risk Highland ponies on the same premises all retained their fetal membranes in the same breeding season. The ponies were treated with a combination of oxytocin, infusion and distension of the allantochorionic sac with fluid, gentle traction in one case, and supportive therapy. The possible causes of the condition were investigated with clinicopathological tests and analyses of the herbage for its species composition and fungal contamination. No obvious possible causative abnormalities were identified apart from a low total serum calcium level in one case. No fescue grass was found and no pathogenic fungi were detected.

In this abdominal pregnancy, the dead fetus was delivered through an abdominal incision at the 36th gestational week. The placenta invaded the small intestine and the omentum was left in situ. The placental degeneration was monitored using serial serum beta-human chorionic gonadotropin values. In certain periods, the follow up of the placental regression was carried out using the Cavalieri method with abdominal ultrasound. It was seen that the placental volume had decreased by 83% at the end of 1 year. To the best of our knowledge, this is the first time this method has been used for this purpose.

The objective was to determine whether daily walking activity and milk yields could be used as predictors of metabolic and digestive disorders early in lactation. Data were collected from 1996 through 1999 from 1445 dairy cows in 3 Florida herds. Walking activity, milk yield, and other measures were collected from a computerized dairy management system. Mixed models analysis was used for data on cows before their first detected estrus, as identified by difference in activity. Healthy cows were defined as those without any metabolic or digestive disorder during the prebreeding stage, whereas a sick cow had an occurrence of those disorders at any time during the prebreeding stage. Metabolic disorders were ketosis, retained placenta, and milk fever. Digestive disorders included displaced abomasum, indigestion, reduced feed intake, traumatic gastritis, acidosis, and bloat. Data from cows with known cases of ketosis, left displaced abomasum, and digestive disorders were analyzed to determine changes in activity and milk yield before those specific disorders were clinically diagnosed. Although walking activity was generally lower among sick cows, cows with ketosis, left displaced abomasum, and digestive disorders had higher than average activity 8, 9, and 8 d, respectively, before each diagnosed disorder. Daily milk yields of sick cows were approximately 15 kg/d less than milk yields of healthy cows. Milk yields were lower by 6, 7, and 5 d, respectively, before diagnoses of ketosis, left displaced abomasum, and digestive disorders. Cows with ketosis, left displaced abomasum, and general digestive disorders could possibly be detected about 5 to 6 d earlier than clinical diagnoses based on changes in daily walking activity and milk yield.

Objective: The objective of this article is to describe the MR imaging appearances of retained products of conception., Conclusion: Retained products of conception appear on MR imaging as an intracavitary uterine soft-tissue mass with variable amounts of enhancing tissue and variable degrees of myometrial thinning and obliteration of the junctional zone. These findings should not be misinterpreted as indicating gestational trophoblastic disease, particularly in the setting of a postpartum patient with a normal or minimally elevated beta-human chorionic gonadotropin level. MR imaging may also be helpful in showing anatomic variants that hinder successful instrumentation of the uterine cavity in patients with suspected retained products of conception.

This case documents a seldom-described event of retained products of conception masquerading as an acquired arteriovenous malformation (AVM) of the uterus. The patient presented with sudden onset of heavy vaginal bleeding 6 weeks after artificial abortion. Ultrasonography and magnetic resonance imaging revealed a diffuse intramural lesion predominantly consisting of prominent vessels, which raised suspicion of an AVM. Hysterectomy revealed retained products of placenta that were necrotic and encroached into thin myometrium.

Background: The incidence of leiomyomas in pregnancy is approximately 1%. Their presence has been linked to spontaneous abortion, premature labor, soft tissue dystocia, uterine inertia, fetopelvic disproportion, malposition of the fetus, retention of the placenta, and postpartum hemorrhage., Case: This case report documents a seldom-described event of a submucous leiomyoma masquerading as retained products of conception. The patient presented 4 weeks postpartum with complaints of urinary retention and heavy bleeding with cramping. Examination revealed a large mass resembling placental tissue filling the vaginal vault. The necrotic mass was removed with blunt and sharp dissection. The final pathology report revealed a degenerating leiomyoma., Conclusion: Complicating factors associated with this fibroid included a history of spontaneous abortion and preterm labor, as well as fetal malpresentation and carneous degeneration of the leiomyoma. Gestational myomas, although rare, can have an unusual appearance that may be misinterpreted.