Search

Background: Uterine sacculation refers to a temporary pouch or sac within the uterus that may contain the placenta or fetal parts and that may be diagnosed antepartum or after delivery. There is very limited published information about this rare condition and its management., Cases: We report two cases of uterine sacculation with entrapped placenta diagnosed immediately postpartum, managed with two different approaches. In one case, the patient underwent immediate laparotomy and placental extraction. In the second case, the patient was managed conservatively but ultimately developed signs of infection and underwent laparotomy., Conclusion: Uterine sacculation with entrapped placenta is a rare condition that is a potential etiology of retained placenta. Obstetric clinicians should be aware of this diagnosis and the management strategies available., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine the incidence, risk factors, and short-term maternal outcomes of women with pathologically confirmed retained products of conception (RPOC) following vaginal delivery., Methods: Prospective cohort study of women with suspicion of RPOC following vaginal delivery, from March 2018 to April 2019. Women were followed for eight weeks postpartum. Women with complete retained placenta were excluded. Women with pathologically confirmed RPOC were compared to those without. Univariate analysis was conducted (ORs; [95% CI]) and was followed by multivariate analysis (aOR; [95% CI])., Results: During the study period, there were 16,583 vaginal deliveries. A total of 96 women (0.58%) with a suspicion of RPOC were enrolled, of these, 53 women (55%) had pathologically confirmed RPOC. The most significant risk factors for pathologically confirmed RPOC were placental abruption (aOR 5.0 [2.29-11.13]) and Oxytocin augmentation of labor (aOR 1.7 [1.07-2.63]). Pathologically confirmed RPOC were associated with higher rates of prolonged hospitalization (OR 9.2 [2.83-30.05]), postpartum hemorrhage (PPH) (OR 6.6 [3.60-11.98]), hemoglobin drop > 3 g/dl (OR 11.4 [5.49-23.49]), and blood transfusion (OR 8.6 [2.07-38.18]). Women who had exploration of uterine cavity without pathological confirmation of RPOC, still had higher rates of perineal laceration (OR 17.6 [4.93-63.08]), PPH (OR 6.1 [3.05-12.21]), and a hemoglobin drop > 3 g/dl (OR 6.0 [2.13-16.95])., Conclusions: Pathologically confirmed RPOC following vaginal delivery has unique characteristics and is associated with significantly higher rates of PPH and blood transfusions. These findings may assist in the development of better criteria for selecting women for manual exploration and for preventive measures to reduce PPH and complications.

Background: There is insufficient high-quality evidence to either support or discourage water birth (WB)., Objectives: To examine different maternal complications of WB compared to standard land birth (LB). The primary outcomes were postpartum hemorrhage and genital trauma. The secondary outcome included the risk of retained placenta and shoulder dystocia., Methods: We searched the electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO. In addition, we searched in Google Scholar and ClinicalTrials.gov. The pooled results were used to evaluate the association between WB and obstetric outcomes. This systematic review (SR) was reported according to PRISMA statement 2020. Statistical meta-analyses were performed using Cochrane RevMan version 5.4 software (http://www.cochrane.org)., Results: This systematic review included 22 studies (20 observational studies and 2 RCT). The pooled results showed lower risk of major PPH compared to the LB group (OR = 0.76, 95% CI: 0.66-0.89), no significant difference (OR: 0.94, 95% CI: 0.50-1.78) in the incidence of minor PPH (500-1000 mL blood loss) between WB and LB, no significant difference in the rate of third- and fourth-degree lacerations (OR = 0.87, 95% CI: 0.71-1.07) and in the incidence of retained placenta (OR = 1.30, 95% CI: 0.50-3,35), fewer shoulder dystocia for WB (OR = 0.42, 95% CI: 0.35-0.50). However, compared with the LB group, the rate of first-second-degree tears in the WB group increased by 45% (OR = 1.45, 95% CI: 1.16-1.81)., Conclusion: We support ACOG guidelines recommendation for further RCT to assess the impact of water immersion during delivery on maternal outcomes., (Copyright © 2022 Elsevier B.V. All rights reserved.)

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.

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).)

Introduction: Third stage placental complications (TSPC) including partially or complete retained placenta, are a common obstetric complication. Previous studies have underlined risk factors for TSPC in heterogenous populations of women, whereas data regarding primigravid term women are scarce. We aimed to identify the factors associated with TSPC in this subset of parturients., Methods: A retrospective cohort study including all primigravid women who delivered vaginally a term, live-singleton neonate between 2011 and 2019. Women who underwent revision of the uterine cavity due to TSPC were compared with those who did not. Univariate and multivariate regression analyses were performed in order to identify the risk factors for TSPC., Results: Overall, 16,867 deliveries met the study inclusion criteria. Of those, 1097 (6.5%) deliveries were complicated by TSPC. Women with TSPC were older (p < 0.001) and with a higher proportion of lateral and fundal placental location (p < 0.001). In a multivariate regression analysis, the following factors were positively independently associated with TSPC: maternal age (aOR [95% CI] 1.26 (1.17-1.36), p < 0.001), the use of assisted reproduction technologies (aOR [95% CI] 1.26 (1.06-1.49), p = 0.007), preeclampsia (aOR [95% CI] 3.39 (1.89-6.10), p < 0.001), thrombocytopenia (aOR [95% CI] 1.83 (1.34-2.48), p < 0.001), oxytocin administration (aOR [95% CI] 1.29 (1.12-1.48), p < 0.001) and longer second stage duration (aOR [95% CI] 1.03 (1.003-1.05), p = 0.02). Fetal male gender was negatively associated with TSPC (aOR [95% CI] 0.80 (0.70-0.92), p = 0.002)., Discussion: We have identified multiple independent risk factors for TSPC among primigravid women. This information can aid in patient counseling and delivery management in these subset of parturients., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Study Objective: To evaluate the reproductive outcomes in women treated for retained products of conception (RPOC) by hysteroscopy (morcellation vs loop resection)., Design: Cohort study., Setting: A teaching and university hospital., Patients: Patients included in a previous randomized controlled trial on hysteroscopic removal of RPOC comparing morcellation (n = 46) with loop resection (n = 40)., Interventions: Hysteroscopic morcellation versus loop resection., Measurements and Main Results: The primary outcome measures were live birth and pregnancy complications (including abnormal placentation [placenta accreta/increta/percreta], placenta previa, vasa previa, retained placenta after delivery or incomplete expulsion with the need for manual removal or curettage, and RPOC), uterine rupture, and other complications (blood loss, preterm labor, preterm premature rupture of membranes, hypertensive disorders of pregnancy, and intrauterine growth restriction). The live birth rate was 88.9% in the morcellation group and 68.2% in the loop resection group (p = .09). Uterine rupture occurred in 1 patient in the morcellation group (4.2%) (p = 1.00). Placental complications were found in 20.8% and 22.2% of the hysteroscopic morcellation and loop resection groups, respectively (p = .33), and other pregnancy complications were seen in 33.3% and 16.6% of the 2 groups (p = .33). The secondary outcome was time to pregnancy. The median time to pregnancy was 14 weeks (interquartile range [IQR], 5-33 weeks) in the morcellation group and 15 weeks (IQR, 6-37 weeks) in the loop resection group (p = .96)., Conclusion: Hysteroscopic removal of RPOC seems to have no detrimental effect on reproductive outcome and no significant effect on pregnancy rate., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: Our primary aim was to report the incidence of enhanced myometrial vascularity (EMV) in consecutive women attending our early pregnancy assessment unit, following first-trimester miscarriage. We aimed further to evaluate the clinical presentation and complications associated with expectant and surgical management of EMV in these women., Methods: This was a prospective cohort study conducted in a London teaching hospital between June 2015 and June 2018, including consecutive patients with an observation of EMV on transvaginal ultrasonography following first-trimester miscarriage. The diagnosis was made following the subjective identification of EMV using color Doppler ultrasonography and a peak systolic velocity (PSV) ≥ 20 cm/s within the collection of vessels. Women were followed up with repeat scans every 14 days. Management was expectant unless intervention was indicated because of excessive or prolonged bleeding, persistent presence of retained tissue in the endometrial cavity or patient choice. The final clinical outcome was recorded. Time to resolution of EMV was defined as the interval from detection of EMV until resolution., Results: During the study period, there were 2627 first-trimester fetal losses in the department and, of these, 40 patients were diagnosed with EMV, hence the incidence of EMV following miscarriage was 1.52%. All cases were associated with ultrasound evidence of retained products of conception (RPOC) at presentation (mean dimensions, 22 × 20 × 20 mm). Thirty-one patients opted initially for expectant management, of which 18 had successful resolution without intervention, five were lost to follow-up and eight subsequently had surgical evacuation due to patient choice. No expectantly managed case required emergency intervention. Nine patients chose surgical evacuation as primary treatment. No significant correlation was seen between PSV within the EMV at presentation and blood loss at surgery. Median PSV was 47 (range, 20-148) cm/s. The estimated blood loss in all cases managed surgically ranged from 20-300 mL. Presence of RPOC was confirmed in all specimens that were sent for analysis following surgery. For cases successfully managed expectantly, the mean time to resolution was 48 (range, 21-84) days. In the nine cases managed surgically from the beginning, the mean time to resolution of EMV was 10.6 (range, 3-29) days., Conclusions: This study suggests that EMV is an uncommon finding following miscarriage and is associated with the presence of RPOC. Expectant management was a safe option in our cohort, with minimal bleeding, although it was associated with protracted time to resolution. In patients who opted for surgery, the maximum blood loss was 300 mL and no patient required blood transfusion or embolization. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage., Study Design: We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm., Results: Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%)., Conclusion: Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to analyze data concerning history, clinical course, and prognosis of retained fetal membranes in mares., Material Und Methods: Patient records of 121 hospitalized mares with retained placenta were evaluated. In 82 cases, additional blood examinations were performed and analyzed., Results: There was no significant correlation between age, parity or course of parturition and retained placenta. Eighty-one mares (66.9 %) were presented solely with retained fetal membranes, 40 mares (33.1 %) had additional diseases at presentation, most commonly injuries of the labia, followed by perineal tears and lochiometra. During hospitalization 50 mares (41.3 %) developed one or more diseases, most frequently lochiometra (23 mares, 19 %), laminitis (17 mares, 14 %) and thrombophlebitis (11 mares, 9.1 %). Eight mares (6.6 %) were euthanized due to the course of their diesease. Blood examinations revealed a mean leucocyte concentration of 9.8 ± 3.9 G/l at presentation. Mean concentration of serum ionized calcium amounted to 1.5 ± 0.2 mmol/l. There was no statistically significant influence of blood parameters on clinical course or development of additional diseases., Conclusion and Clinical Relevance: Retained placenta is a common disorder in the puerperium of the mare. In the presented study, most cases developed additional diseases and in 10 % of the mares, the clinical course led to euthanasia. No risk factors for the occurrence of retained fetal membranes or its clinical course could be identified., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To compare the prevalence of postpartum retained products of conception (RPOC) among parturients with a history of third stage of labor placental complications and parturients without those complications., Study Design: All women operated for postpartum RPOC following vaginal delivery by hysteroscopy or suction curettage between January 2013 and December 2017 were included in the study. Their medical records were reviewed for the occurrence of third stage of labor placental complications (including early postpartum hemorrhage treated with uterotonics, manual separation of the placenta, and revision of the uterine cavity for removal of cotyledons)., Results: The study cohort included 172 women operated for postpartum RPOC following vaginal delivery by operative hysteroscopy (143 cases, 83.1%) or by suction curettage (29 cases, 16.9%). Third stage of labor placental complications were reported in 65 (37.8%) cases, while 107 (62.2%) women had an uncomplicated third stage of labor. When considering all vaginal deliveries in our institution during the study period, the risk for RPOC was significantly higher among parturients with third stage of labor placental complications compared to those with an uneventful third stage of labor (3.7% versus 0.3%, p < 0.001, Odds ratio = 12.5, 95% confidence interval 9.0-17.3)., Conclusion: Postpartum RPOC following vaginal delivery were more common in parturients with third stage of labor placental complications. However, the majority of postpartum RPOC cases were diagnosed in women reported to have an uncomplicated third stage of labor. Thus, focused postpartum ultrasound follow-up of women considered at risk for RPOC will not identify all cases., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study is to assess risk factors and complications of manual placental removal., Materials and Methods: An historical prospective study of all parturients undergoing manual placental removal between 2012 and 2014. Parturients were matched by time of delivery with parturients delivering vaginally with spontaneous placental separation. Multiple gestations, preterm deliveries, incomplete placental separation and uterine malformations were excluded. Delivery characteristics and short-term complications were studied. Telephone questionnaires were conducted to assess the likelihood of invasive procedures performed for retained products of conception (RPOC) up to 12 weeks postpartum., Results: Overall 293 (1.5% of all vaginal deliveries) were complicated by manual placental removal. Independent risk factors included advanced maternal age (odds ratio (OR) 1.08, 95% CI 1.03-1.12), previous manual removal (OR 9.27, 95% CI 3.15-27.31), regional anesthesia (OR 3.49, 95% CI 2.14-5.70), and labor induction (OR 1.80, 95% CI 1.12-2.88). Short-term complications included blood product transfusions (OR 18.26 95% CI 5.37-62.13) and prolonged hospitalization (OR 1.51 95% CI 1.06-2.16). Invasive procedures for removal of RPOC occurred in 12.2% of women in the study groups and in none of the women in the control group (p < .001)., Conclusions: Manual placental removal harbors short- and long-term complications, including a high likelihood of RPOC necessitating further invasive procedures.

In dairy cows, retained fetal membranes (RFM) affect reproductive performance. The aim of this study was to examine the leukocyte counts and the gene expression of tumour necrosis factor α (TNFα), interleukin 1β (IL-1β), IL-8, and IL-10 in polymorphonuclear leukocytes (PMNs) and peripheral blood mononuclear cells (PBMCs) in cows with (n = 5) or without (n = 5) RFM during the peripartum period. The lymphocyte counts in RFM cows were higher than those in control cows throughout the experiment (p < .05). The expression of IL-8 in PMNs of control cows was higher (p < .05) compared with that of RFM cows postpartum. In cows with RFM, IL-1β expression was higher (p < .05) in PMNs at 6 weeks postpartum whereas the expression of IL-1β was lower (p < .05) in PBMCs at 4 weeks postpartum. The expression of IL-10 in PBMCs of control cows was higher (p < .05) than that of RFM cows at 2 weeks prepartum and 4 weeks postpartum. Taken together, our data indicate that changes of gene expression of pro- and anti-inflammatory cytokines in RFM cows might be associated with the delayed placental separation and development of uterine inflammation in RFM cows., (© 2018 Japanese Society of Animal Science.)

Objective: The objective of this study was to determine the incidence of morbidly adherent placenta in pregnancies after endometrial ablation., Study Design: We performed a retrospective cohort analysis using a large, multiinstitutional deidentified clinical database, IBM EPM: Explore (IBM Corporation, Somers, NY). We identified women who underwent endometrial ablation and had a subsequent delivery between 1999 and 2016. Patients with a delivery and no prior ablation were used as controls. The association between morbidly adherent placenta, ablation, and other known risk factors for morbidly adherent placenta was analyzed using multivariable logistic regression., Results: Of 162,100 reproductive-aged women who underwent endometrial ablation, 2,770 women (1.71%) subsequently had a delivery. The rate of morbidly adherent placenta was 1 in 13.9 pregnancies after ablation compared with 1 in 838.7 pregnancies in the control group (adjusted odds ratio [aOR], 20.22, p  < 0.0001)., Conclusion: Pregnancies that occurred after endometrial ablation were associated with increased rates of morbidly adherent placenta., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

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.

The objective of this study was to evaluate the association of postpartum plasma Ca concentration with early-lactation disease outcomes, culling within 60 d in milk, pregnancy to first service, and milk production. A total of 1,453 cows from 5 commercial dairy farms in New York State were enrolled in a prospective cohort study from February to November 2015. Blood samples were collected within 12 h of parturition, and plasma was submitted to a diagnostic laboratory for total Ca measurement. Early-lactation disease, reproductive performance, and milk production from Dairy Herd Improvement Association (DHIA) test-day data were compiled from each farm's management software. Multivariable Poisson regression models were built to evaluate the association of plasma Ca with the risks of retained placenta (RP), metritis, displaced abomasum (DA), clinical mastitis, culling within 60 d in milk, and pregnancy to first service. Repeated-measures ANOVA were used to evaluate the association of Ca at parturition with milk production across the first 9 DHIA tests. Herd was considered a random effect in all models. Primiparous cows were modeled separately from multiparous cows if differential responses were observed. Calcium was not associated with the risk of RP, metritis, clinical mastitis, or pregnancy to first service in primiparous or multiparous cows. For multiparous cows only, higher Ca concentration tended to be associated with increased culling within the first 60 d in milk. Multiparous cows with Ca ≤1.85 mmol/L had an increased risk of being diagnosed with a DA compared with cows with Ca >1.85 mmol/L. For the milk production models, Ca was not associated with the amount of milk produced within the first 9 DHIA tests in primiparous cows; however, multiparous cows with Ca ≤1.95 mmol/L produced, on average, 1.1 kg more milk per day across the 9 DHIA tests than their multiparous counterparts with Ca >1.95 mmol/L. Our results indicate that plasma Ca concentration measured within 12 h of parturition is a poor predictor of early-lactation health outcomes. Reduced Ca concentration in the immediate postpartum period was associated with higher milk production in multiparous cows. From these results, we caution that studies attempting to categorize subclinical hypocalcemia based on a single sample in the immediate postpartum period could misclassify the disorder., (Copyright © 2018 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Background: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL., Methods: As part of a prospective dose escalation study conducted at Modilon Hospital in Papua New Guinea, women with a singleton pregnancy in cephalic presentation and an unfavourable cervix who gave written informed consent were administered oral misoprostol, commencing at 25mcg once every 2 h for 4 doses and increased to 50mcg once every 2 h for 8 doses within 24 h. The primary outcomes studied were i) the proportion of women delivering within 24 h of oral misoprostol administration, and ii) rates of maternal and perinatal severe adverse events., Results: Of 6167 labour ward screened admissions, 209 women (3%) fulfilled the study inclusion criteria and underwent IOL. Overall, 74% (155/209 [95% confidence interval 67.6-79.9]) delivered within 24 h. Most women (90%; 188/209; 95% CI [84.9-93.5]) delivered vaginally with 86% (180/209) having a good outcome for both the mother and baby. Of the 10% (21/209) who failed IOL and underwent caesarean section, a significant proportion of their babies were admitted to special-care nursery compared to babies delivered vaginally (20/21 [95%] versus 8/188 [4%]; Fisher Exact test P < 0.001), but their perinatal mortality rate was not significantly higher (1/21 [5%] versus 2/188 [1%]; P = 0.30). The only maternal death was not study related and occurred in a patient with post-partum haemorrhage, 15 h post-delivery., Conclusion: The oral misoprostol regimen for IOL described in the present study is safe, effective and logistically feasible to administer in a resource-limited setting.

Objective: To determine risk factors for retained placenta, and to identify supporting epidemiologic evidence for the three previously-proposed mechanisms: (i) invasive placentation, (ii) placental hypo-perfusion, and (iii) inadequate uterine contractility., Design: A retrospective population-based cohort study., Setting and Population: Israeli population in the southern district., Methods: Data were analyzed from a tertiary hospital database, between 1989 and 2014, using univariate tests and generalized estimating equation (GEE) multivariable models., Main Outcome Measures: Prevalence of retained placenta., Results: The study population included 205,522 vaginal deliveries of which 4.8% (n=9870) were complicated with retained placenta. Previous intra-uterine procedures and placenta-related pregnancy complications were found to be significant risk factors for retained placenta (history of cesarean section aOR=8.82, 95%CI 8.35-9.31; history of curettage aOR=12.80, 95%CI 10.57-15.50; pre-eclampsia aOR=1.25, 95%CI 1.14-1.38; delivery of a small for gestational age neonate aOR=1.08, 95%CI 1.01-1.16; stillbirth aOR=2.34, 95%CI 1.98-2.77). During labour, the risk for retained placenta was increased in presence of arrest of dilatation (aOR=2.03, 95%CI 1.08-3.82) or arrest of descent (aOR=1.55, 95%CI 1.22-1.96). Infections of the uterine cavity during labour were also found to be strongly associated with increased risk of retained placenta (endometritis aOR=2.21, 95%CI 1.64-2.97; chorioamnionitis aOR=3.35, 95% CI 2.78-4.04)., Conclusions: Supporting epidemiologic evidence were found for all three underlying mechanisms. In addition, there is evidence to suggest that intrauterine infection and inflammation may also be a possible pathology associated with retained placenta., Tweetable Abstract: Risk factors for retained placenta support previously proposed mechanisms in a large cohort study., (Copyright © 2017 Elsevier B.V. All rights reserved.)

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., (Copyright © 2017 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.)

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).)

Objectives: To explore the influence of epidural analgesia on the course of the third stage of labor and on the incidence of the complete retained placenta as well as retained parts of the placenta., Study Design: This is a population-based cohort study in a tertiary medical center. We collected data from all 4227 spontaneous singleton vaginal deliveries during 6 months and compared the incidence of retained placenta in deliveries with epidural analgesia with those without analgesia. Multivariable logistic regression was used to control for possible confounders., Results: More than two-thirds of the women (69.25%) used epidural analgesia during their delivery. A need for intervention due to placental disorder during the third stage of labor was noted in 4.2% of all deliveries. Epidural analgesia appeared to be significantly (P=0.028) related to placental disorders compared with no analgesia: 4.8% vs. 3%, respectively. Deliveries with manual interventions during the third stage, for either complete retained placenta or suspected retained parts of the placenta, were associated with the use of epidural analgesia (P=0.008), oxytocin (P=0.002) and older age at delivery (P=0.000), but when including all factors in a multivariable analysis, using a stepwise logistic regression, the factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and, marginally, older age., Conclusions: Complete retained placenta and retained parts of the placenta share the same risk factors. Epidural analgesia does not directly influence the incidence of complete retained placenta or retained parts, though clinically linked through increased oxytocin use. The factors that were independently associated with interventions for placental disruption during the third stage of delivery were previous cesarean section, oxytocin use and older age.

Although the incidence of morbidly adherent placenta (MAP) has risen progressively in the last two decades, there remains uncertainty about the diagnosis and management of this condition. The aim of this review is to provide up-to-date and evidence-based answers to common clinical questions regarding the diagnosis and management of MAP. Different risk factors have been associated with MAP; however, previous Cesarean section and placenta previa are the most frequently associated. Ultrasound is the primary method for diagnosing MAP and has a good overall diagnostic accuracy for its detection. When considering the different ultrasound signs of MAP, color Doppler seems to provide the best diagnostic performance. Magnetic resonance imaging has the same accuracy in diagnosing MAP as does ultrasound examination; its use should be considered when a resective procedure, such as hysterectomy, is planned as it can provide detailed information about the topography of placental invasion and predict difficulties that may arise in surgery. The optimal gestational age for delivery in pregnancies with MAP is yet to be established; planning surgery between 34 and 36 weeks of gestation provides the best balance between fetal maturity and the risk of unexpected episodes of heavy bleeding, which are more likely to occur with delivery after this timepoint, especially in severe cases of MAP. The optimal surgical approach to MAP depends on multiple factors, including availability of an experienced team, specific surgical skills and hospital resources. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.)

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.)

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.

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center., Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly., Results: Overall, 33,925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23-2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68-0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30-2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27-2.00) and vacuum delivery (OR 1.89, 95% CI 1.48-2.41) were independently associated with uterine revision for retained placenta., Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.

Objective: To evaluate whether defective placentation disorders, i.e. pre-eclampsia, stillbirth, small for gestational age (SGA), and spontaneous preterm birth, are associated with risk of retained placenta., Design: Population-based cohort study., Setting: Sweden., Population: Primiparous women in Sweden with singleton vaginal deliveries between 1997 and 2009 at 32-41 weeks of gestation (n = 386,607), without placental abruption or infants with congenital malformations., Methods: Risks were calculated as odds ratios (ORs) by unconditional logistic regression with 95% confidence intervals (95% CIs) after adjustments for maternal, delivery, and infant characteristics., Main Outcome Measure: Retained placenta, defined by the presence of both a diagnostic code (of retained placenta) and a procedure code (for the manual removal of the placenta)., Results: The overall rate of retained placenta was 2.17%. The risk of retained placenta was increased for women with pre-eclampsia (adjusted OR, aOR, 1.37, 95% CI 1.21-1.54), stillbirth (aOR 1.71, 95% CI 1.28-2.29), SGA birth (aOR 1.47, 95% CI 1.28-1.70), and spontaneous preterm birth (32-34 weeks of gestation, aOR 2.35, 95% CI 1.97-2.81; 35-36 weeks of gestation, aOR 1.55, 95% CI 1.37-1.75). The risk was further increased for women with preterm pre-eclampsia (aOR 1.69, 95% CI 1.25-2.28) and preterm SGA birth (aOR 2.19, 95% CI 1.42-3.38). There was no association between preterm stillbirth (aOR 1.10, 95% CI 0.63-1.92) and retained placenta, but the exposed group comprised only 15 cases., Conclusions: Defective placentation disorders are associated with an increased risk of retained placenta. Whether these relationships indicate a common pathophysiology remains to be investigated., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Subacute ruminal acidosis in dairy cows occurs when ruminal pH is below about 5.5. However, the exact threshold level of ruminal pH affecting cow health is still in debate. This investigation was carried out in 505 cows within 31 farms. The postpartum disorders, including dystocia, retained placenta, anestrus, cystic ovary, metritis, clinical mastitis and lameness, were analyzed. Ruminal pH, serum beta-hydroxy butyrate (SBHB), serum urea nitrogen and body condition score (BCS) were measured once during the 3 to 6 weeks postpartum, while BCS was determined once more at 1 week before calving. Ruminal pH was determined by ruminocentesis technique. The ruminal pH was evaluated to study the association with BCS, SBHB and postpartum disorders using linear regression in a generalized linear mixed model with farm as a random effect. The results show that low ruminal pH was associated with dystocia, metritis and lameness. Moreover, a low ruminal pH can be found in cows with a high loss of BCS after calving and also in cows with low SBHB postpartum. These findings confirmed the feasibility of the ruminocentesis technique and the association of low ruminal pH on various postpartum disorders at the individual cow level. However, the consequences of low ruminal pH on dairy cow health still needs more exploration for a better understanding of the physiological mechanisms., (© 2014 Japanese Society of Animal Science.)

Retained placenta (RP), defined as fetal membranes not being expelled within 24 h after calving, is a costly disease in multiparous dairy cows that has been linked to immune suppression, infections, elevated lipid mobilization, and depleted status of antioxidants including α-tocopherol, and that increases the risk of other diseases (OD) in early lactation. Early detection of cows at increased risk of developing RP, OD, or both in early lactation could improve treatment success and result in improved milk production and reproductive performance. To identify risk indicators of RP, OD, or both, we used a nested case-control design and compared multiparous dairy cows that developed RP (n=32) with cows that remained healthy (H; n=32) or cows that developed OD (n=32) in early lactation. We compared peripartal body condition score (BCS) as well as serum concentrations of α-tocopherol, metabolites [β-hydroxybutyrate (BHBA), cholesterol, glucose, nonesterified fatty acids (NEFA), and urea N], haptoglobin, and macrominerals (i.e., calcium, magnesium, and phosphorus) on d -21, -14, -7, -3, -1, 0, 1, 3, 7, 14, 21, 28, 35, 42, and 49 postpartum. In addition, average serum concentrations were calculated for each cow for the last 3 wk prepartum, for 3 and 2 wk prepartum combined, for the last week prepartum, and for the morning after calving and compared between groups. The RP cows had lower BCS than the H or OD cows until 2 wk postpartum. During the prepartal periods, RP and OD cows had lower α-tocopherol concentrations (corrected or not for cholesterol concentration) and higher NEFA and BHBA concentrations than H cows. Thus, lower prepartal BCS could be an early predictor for RP risk, and lower α-tocopherol concentrations and higher NEFA and BHBA concentrations could be early predictors for disease., (Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to investigate whether induction of labor in twin pregnancies is associated with higher rates of maternal complications as compared to singletons., Method: A retrospective population-based study was conducted to compare maternal complications following induction of labor in twin pregnancies and singletons at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders., Results: The study population included 25 913 patients following induction of labor, of these 191 (0.73%) were in twin pregnancies. Induction of labor in twin pregnancies was not associated with adverse maternal outcomes such as cervical tears, third degree perineal tears, uterine rupture, peripartum hysterectomy, post-partum hemorrhage or retained placenta. However, labor induction in twins was significantly associated with cesarean deliveries (31.2% versus 17.1%; p < 0.001). Using a multivariable analysis controlling for confounders, induction at twins was an independent risk factor for cesarean delivery (CD; adjusted OR = 2.2, 95% CI 1.7-2.7, p < 0.001)., Conclusion: Induction of labor in twin pregnancies does not increase the risk for maternal complications. However, it is an independent risk factor for CD.

As the etiopathology of retained placenta is still not resolved in cattle, we compared the effects of protracted induction of parturition (PIP) and conventional induction of parturition (SIP) on placental maturation and the occurrence of retained placenta. PIP was induced in 13 cows by administration of 1.3 mg dexamethasone im twice daily between Days 268 and 273 of gestation and 40 mg dexamethasone im on Day 274 of gestation. For SIP, 10 cows received a single injection of 40 mg dexamethasone on Day 274 of gestation. A third group (SPON, n = 11) served as a nontreated control group. Within 2 hours after birth, two placentomes were extracted from the uterus and used for assessment of placental maturation by histology and immunohistochemistry. Incidence of retained placenta was lower (P < 0.05) in group SPON (9%) compared with groups PIP (54%) and SIP (70%). Staining with Masson's trichrome and pan-cytokeratin indicated a higher degree of atrophy and flatness of the maternal crypt epithelium in cows with physiological release of fetal membranes (REL) compared with cows with retained placentae (RET). Staining with anti-caspase-3 ratified the observations as more apoptotic cells were detected in groups SPON and PIP compared with group SIP; however, data were not statistically significant. Additionally, the expressions of the potent vasodilators endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) were evaluated. Both eNOS and iNOS were only expressed in chorionic tissue. Endothelin-1 (ET-1), a major vasoconstrictor, showed positive staining in maternal crypt epithelium and in chorionic epithelium. No differences were found for iNOS and eNOS and ET-1, neither among the experimental groups nor between RET and REL cows. These findings indicate that a PIP results in increased placental maturation, but does not influence the incidence of placental retention in cows. The expression of vasoactive substances does not seem to be related to the placental separation process., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The objectives of the present study were to compare the effects of a protracted and a conventional induction of parturition on the incidence of retained placenta, and to evaluate the suitability of transrectal Doppler sonography of the uterine arteries as a noninvasive method for the assessment of placental maturation. Protracted induction of labor (PIP) was precipitated in 13 cows by the administration of 1.3 mg dexamethasone im twice daily between Days 268 and 273 of gestation, and 40 mg dexamethasone im on Day 274 of gestation. For conventional induction of labor (SIP), 10 cows received 40 mg dexamethasone on Day 274 of gestation. A third group was not treated and served as control (SPON; N = 11). Blood flow volume (BFV) and resistance index in the uterine arteries were measured with Doppler sonography once a day from Day 268 of gestation until labor. After each ultrasonographic examination, blood samples for determination of steroid hormones were taken. Incidence of retained placenta was lower (P < 0.05) in group SPON (9%) compared with groups PIP (54%) and SIP (70%). In the last 7 days before parturition uterine BFV and resistance index did not change (P > 0.05) and did not differ between groups SPON, PIP, and SIP (P > 0.05). Resistance index was higher (P < 0.001) in cows with retained placenta compared with cows with released placenta, and BFV did not differ (P > 0.05) between them. Total estrogen concentrations increased by 283% (P < 0.001) in group PIP and by 60% (P < 0.05) in group SPON between Days -7 and -1 before parturition. They stayed constant (P > 0.05) until Day -2 in group SIP, but increased (P < 0.05) after the high dosage of dexamethasone within 1 day by 140%. Total estrogen levels were higher (P < 0.05) in cows with released placenta than in cows with retained placenta. In conclusion, a protracted compared with a short induction of labor results in higher estrogen levels before term, but does not affect incidence of placental retention. Neither alterations in placental maturation nor changes in steroid hormones influenced uterine blood supply. Therefore, Doppler sonography of uterine arteries is unsuitable to investigate the process of placental maturation induced by glucocorticoids in cows. Nevertheless, disturbances in the placental maturation process in cows with retained fetal membranes after parturition can be detected before parturition by a higher uterine blood flow resistance in the uterine arteries., (Copyright © 2013 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.

Background: Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP., Study Design: Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010., Results: The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1)., Conclusions: History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To identify factors related to retained placenta in the context of contemporary obstetric practice., Methods: This was a case-control study comparing 408 cases of retained placenta and an equivalent number of control individuals. Epidemiological and delivery-related variables were registered in computerized prenatal and in-hospital medical records. Univariable and multivariable logistic regressions were used for estimation of risk ratios and statistical significance., Results: Independent risk factors for retained placenta were: previous retained placenta (odds ratio [OR] 12.61, 95% confidence interval [CI] 3.61-44.08); preterm delivery (OR 3.28, 95% CI 1.60-6.70); oxytocin use for 195-415 minutes (OR 2.00, 95% CI 1.20-3.34); oxytocin use more than 415 minutes (OR 6.55, 95% CI 3.42-12.54, number needed to harm 2.3); preeclampsia (OR 2.85, 95% CI 1.20-6.78); two or more previous miscarriages (OR 2.62, 95% CI 1.31-5.20); and one or more previous abortion (OR 1.58, 95% CI 1.09-2.28). Parity of two or more had a seemingly protective effect (OR 0.40, 95% CI 0.24-0.70), as did smoking at the start of pregnancy (OR 0.28, 95% CI 0.09-0.88). Retained placenta was significantly associated with an increased risk of postpartum hemorrhage. The OR related to blood loss exceeding 500 mL, 1,000 mL, and 2,000 mL and the need for blood transfusion was 33.07 (95% CI 20.57-53.16), 43.44 (95% CI 26.57-71.02), 111.24 (95% CI 27.26-454.00), and 37.48 (95% CI 13.63-103.03), respectively. Diabetes was numerically overrepresented in the case group, but the power of the study to detect a significant difference in risk outcome was insufficient., Conclusion: Identifying risk factors for retained placenta is important in the assessment of women after delivery. The increased risk associated with duration of oxytocin use is of interest, considering its widespread use., Level of Evidence: II.

The mechanisms underlying detachment of foetal membranes after birth in cows are still unclear. To address this problem in a systematic manner, we performed the first holistic transcriptome study of bovine placentomes antepartum (AP; n=4 cows) and intrapartum (IP; n=4 cows) using Affymetrix GeneChip Bovine Genome Arrays. Three placentomes were extracted from each cow, and tissue samples from the contact zones of the placentomes (foeto-maternal units) were recovered by systematic random sampling and processed for RNA extraction and for stereological quantification of cellular composition. Statistical analysis of microarray data (false discovery rate 1%) revealed 759 mRNAs with at least twofold higher levels in the samples of the AP group, whereas 514 mRNAs showed higher levels in the IP group. The differentially expressed genes were classified according to biological processes and molecular functions using the Functional Annotation Clustering tool of the DAVID Bioinformatics Resources. Genes with higher mRNA levels in the AP group were nearly completely related to mitotic cell cycle and tissue differentiation. During parturition, a complete shift occurred because the genes with higher mRNA levels in IP were nearly all related to three different physiological processes/complexes: i) apoptosis, ii) degradation of extra cellular matrix and iii) innate immune response, which play a fundamental role in placental detachment. These results are an excellent basis for future studies investigating the molecular basis of retained foetal membranes.

Objectives: Retained placenta after cesarean delivery (RPAC) is a rare phenomenon that has not been previously studied in detail. The objective of our study was to identify potential risk factors that predispose to the development of this obstetrical complication., Methods: We performed a retrospective case-control study comparing 20 cases of RPAC with 40 matched controls, using logistic regression models to test likely risk factors., Results: RPAC occurred in 0.16% of cesarean deliveries in our population. The crude odds ratio (OR) of RPAC was increased in patients who had preterm delivery (PTD) (OR=9.06, 95% CI: 2.04-40.29), conceived with artificial reproductive technology (ART) (OR=5.03, 95% CI: 1.24-20.40), and carried multiples (OR=18.89, 95% CI: 2.29-151.23). Conversely, for each week of gestation the odds of RPAC decreased by 0.57 (95% CI: 0.40-0.82)., Conclusions: Earlier gestational age, PTD, use of ART and multiples are associated with increased OR of RPAC.

The objective of this study was to improve the reproductive efficiency of dairy cows with puerperal metritis (PM) subsequent to retained placenta (RP) using a two-step treatment strategy. A total of 188 postpartum cows, aged from 2 to 8 years, were utilised for 2 experiments. In Experiment 1, cows affected with RP/PM were randomly assigned to two treatment groups. Cows in Group A (n = 17) were treated with 600 mg of ceftiofur intramuscularly for 3 days followed by intrauterine lavage with 0.1% chlorhexidine and infusion with 0.5% povidoneiodine, while cows in Group B (n = 16) received two intrauterine infusions, first with 5 g of oxytetracycline and then with 0.5% povidone-iodine. Cows with normal postpartum findings were regarded as the healthy control group (n = 26). Ultrasonographic examination revealed that the ovarian activities including the appearance of a dominant follicle and days to first ovulation of the cows in Group A during the early postpartum period differed from those of Group B (P < 0.05), which coincided with the results of uterine swabbing for bacteriology. In Experiment 2, cows with normal postpartum findings were allocated to Group D (n = 78), which received an ovulation protocol (GnRH - 7 d PGF2α - 48 h hCG - 24 h AI) on day 50 ± 2 postpartum. Cows affected with PM were randomly divided into two groups, Group E (n = 25) combined the treatments applied in Groups A and D, while Group F (n = 26) repeated the treatment administered in Group E except for uterine lavage. The results indicated that the pregnancy rate within 150 days postpartum and the mean days open in Group E (76.0% and 106.3 ± 4.6 days, respectively) were significantly different from those in Group F (38.5% and 137.9 ± 10.9 days, respectively) (P < 0.05). This study suggests that reproductive efficiency could be improved by using the two-step treatment to regulate uterine involution and an early resumption of ovarian function in cows with RP/PM.

Placenta accreta refers to any abnormally invasive placental implantation. Diagnosis is suspected postpartum with failed delivery of a retained placenta. Massive obstetrical hemorrhage is a known complication, often requiring peripartum hysterectomy. We report a case of presumed placenta accreta in a patient following failed manual removal of a retained placenta. We describe an attempt at conservative management with methotrexate in a stable patient desiring future fertility. Treatment was unsuccessful and led to the development of a disseminated intrauterine infection complicated by a bowel obstruction, requiring both a hysterectomy and small bowel resection. In hemodynamically stable patients, conservative management of placenta accreta may involve leaving placental tissue in situ with subsequent administration of methotrexate. However, ongoing close observation is required to identify complications.

Approximately 5 per cent of dairy cows are affected by retained fetal membranes. Retained fetal membranes are an important risk factor for the metritis/endometritis disease complex occurring in early lactation, and costs the UK dairy industry approximately pound16 million annually in lost production. Veterinary clinicians have described the clinical signs, treatment and some associated risk factors of the condition since early Victorian times, and these have not changed over time. Research carried out within the past 20 years suggests that there is an immunological basis for retained fetal membranes. In a normal calving, the maturation of the placenta and its separation from healthy caruncles depends upon incompatibility between maternal and fetal major histocompatibility complex class I expressed on epithelium within the fetomaternal unit. Placental maturation follows stimulation of the maternal immune response and the production of neutrophil-activating factors within the epithelium in the caruncular arcade. This affects the extracellular matrix components within the placentome, breaking down collagen within the chorionic villi and assisting in separation from the caruncle. Factors influencing normal placental maturation include downregulation of antioxidative defence mechanisms against reactive oxygen species, a lower ratio of prostaglandin E(2) to prostaglandin F(2alpha) within the fetomaternal compartments of the placentome, and an elevated steroid hormone receptor status, which reduces the rate of apoptosis occurring in the chorionic epithelium before calving.

Objective: To document an increased prevalence of retained placenta in mothers with homozygous sickle cell disease., Methods: A retrospective review (January 1, 1992, to December 31, 2005) at the University Hospital of the West Indies revealed 174 singleton deliveries in women with sickle cell disease who were matched by delivery date and age 1:1 with 174 mothers with normal hemoglobin phenotype. Cesarean delivery in 62 mothers (36%) with sickle cell and in 41 women with normal hemoglobin (24%) left 112 sickle cell and 133 normal hemoglobin pregnancies with spontaneous deliveries. Retained placenta was defined by an interval of at least 30 minutes. Duration and details of the third stage of delivery were obtained by review of records. Duration of delivery stages was assessed by Kaplan-Meier survival charts and tested using the log rank test. Known risk factors were sought by logistic regression or exact logistic regression when the number of outcomes was small., Results: First-stage duration was similar in maternal genotypes (sickle cell 470 minutes [median] compared with normal hemoglobin 335 minutes [median]), but in sickle cell disease, the second stage was slightly delayed (sickle cell 16 minutes compared with normal hemoglobin 15 minutes) and the third stage (sickle cell 7 minutes compared with normal hemoglobin 6 minutes). Retained placenta occurred in 20 mothers (17.9%) with sickle cell (interval 30-340 minutes) compared with four among the women in the control group (3.0%, 30-107 minutes). Apart from a weak association with combined oxytocin and misoprostol, there were no significant associations with known risk factors or with hematologic indices within sickle cell disease., Conclusion: Retained placenta is common among mothers with sickle cell disease, and the lack of association with known risk factors suggests that maternal sickle cell disease may be a risk factor., Level of Evidence: II.

Objective: The purpose of this study was to describe normal sonographic appearances of the endometrium in asymptomatic women after elective termination of pregnancy (TOP) and to determine whether sonographic findings are discriminatory in symptomatic women after TOP., Methods: Sonographic parameters were compared in prospectively recruited women after elective TOP. The first 38 were asymptomatic. In a later group, 105 had symptoms suggestive of retained products of conception (RPOC). Endometrial thickness, cavity irregularity, echogenicity of cavity contents, color Doppler flow, and resistive indices (RIs) were assessed. In the symptomatic group, sonographic findings were correlated with symptoms and histologic results., Results: There was a marked overlap in sonographic appearances between the groups. The endometrial cavity is commonly irregular and thickened and may show prominent color Doppler flow in women with an uneventful course as well as in women with histologically proven RPOC. Differences between asymptomatic and symptomatic women were only seen for: endometrial thickness (10.8 mm [range, 1-29 mm] versus 15.3 mm [range, 1.8-34 mm]; P = .0005), and cavity irregularity was greater in symptomatic women (P = .001). Color Doppler flow mean RIs were similar. Symptoms were similar in women proceeding to curettage versus no curettage; no significant relationship was found between individual symptoms and sonographic parameters. Chorionic villi were seen in 47 of 56 women (84%) with positive histologic results., Conclusions: Sonographic appearances and symptoms correlate poorly with each other and with histologic results. Sonography has limited benefits in triaging women with suspected RPOC after TOP in the first trimester. Our findings support a more conservative approach to suspected RPOC after TOP.

Objective: To estimate the risk of complications of the third stage of labour needing manual revision of uterine cavity or curettage in deliveries following one or multiple induced abortions in nulliparous women who had singleton live births in Estonia in 1994-2002., Methods: Registry study using the data from the Estonian medical birth registry: 32,652 women had not had any abortions, 7,333 women had had one and 2,383 women had had two or more surgically induced abortions before their first delivery. Multiple logistic regression analysis was performed to estimate crude odds ratios (OR), adjusted ORs and their 95% confidence intervals, with women having had no abortions as the reference group. Adjustment was made for maternal age, sex and weight of infant, labour induction/augmentation., Results: In the single abortion group, the crude OR was 1.25 (95% confidence intervals (CI) 1.12-1.40), the adjusted OR was 1.23 (95% CI 1.10-1.38); in the multiple abortion group the crude OR was 1.28 (95% CI 1.06-1.53), the adjusted OR was 1.24 (95% CI 1.03-1.49)., Conclusions: Our findings suggest a positive association between one or more first trimester abortion(s) and the risk of complications in the third stage of labour in subsequent singleton delivery.