What is the management of retained placenta in preterm delivery?

Management of Retained Placenta in Preterm Delivery

Manual removal of the placenta should not be performed outside specialized structures to reduce the risk of postpartum hemorrhage, except in cases of severe and uncontrollable postpartum hemorrhage. 1

Definition and Risk Assessment

Retained placenta is diagnosed when:

• The placenta does not spontaneously deliver within 30 minutes after delivery of the fetus
• Significant hemorrhage occurs prior to placental delivery

Risk factors for retained placenta in preterm delivery include:

• Preterm gestational age itself
• Prolonged oxytocin use during labor
• History of prior retained placenta
• Congenital uterine anomalies
• IVF conceptions
• Prior uterine surgery 2

Initial Management Approach

First-line interventions:

1. Administer oxytocin: 5-10 IU slow IV or intramuscular infusion at the time of shoulder release or immediately postpartum 1
2. Controlled cord traction: Gentle traction with counter-pressure on the uterine fundus
3. Intra-umbilical oxytocin: If the placenta remains undelivered after 30 minutes:
   • Inject 50 IU oxytocin diluted in 30 mL normal saline into the umbilical vein
   • This approach has shown a success rate of 51.7% compared to 20.7% with saline alone 3
   • Reduces the need for manual removal by up to 70% 4

Second-line interventions:

1. Sublingual nitroglycerin: Consider when oxytocin fails

   • Can significantly reduce the need for manual removal of placenta
   • Monitor for hemodynamic changes (lowered blood pressure, increased pulse) 5

2. Tranexamic acid: If postpartum hemorrhage occurs

   • Administer 1g IV within 1-3 hours of bleeding onset
   • Reduces maternal morbidity and mortality 1

When to Proceed to Manual Removal

Manual removal of the placenta is indicated when:

• Severe and uncontrollable postpartum hemorrhage occurs
• Medical management fails after appropriate attempts
• Signs of hemodynamic instability develop

When performing manual removal:

• Ensure adequate analgesia
• Consider prophylactic antibiotics (though evidence is inconsistent)
• Be prepared for potential hemorrhage 2

Special Considerations for Preterm Delivery

1. Increased vigilance: Some experts suggest considering intervention earlier (at 15 minutes rather than 30) in preterm cases due to increased hemorrhage risk 6

2. Antibiotic administration: Broad-spectrum antibiotics are recommended during expectant management of preterm premature rupture of membranes at ≥24 weeks to prolong pregnancy and reduce newborn infections 1

3. Cervical cerclage management: If a cerclage is present with PPROM, it is reasonable to either remove it or leave it in situ after discussing risks and benefits 1

Management of Placenta Accreta Spectrum

If a separation plane between placenta and uterus is particularly difficult to create:

• Consider placenta accreta spectrum (PAS)
• Prepare for significant hemorrhage
• Conservative management options include:
  • Leaving the placenta in situ (expectant management)
  • Removal of focal placental adherence with repair of the resulting defect
  • En bloc removal of the uteroplacental defect 1

Pitfalls and Caveats

1. Avoid methotrexate: Despite previous use, methotrexate is not recommended for hastening placental resorption due to:

   • Unproven benefit
   • Potential maternal hematologic and nephrologic toxicities
   • Contraindication in breastfeeding
   • Reports of severe toxicity and septic shock 1

2. Beware of delayed complications: Even after successful management, monitor for:

   • Delayed hemorrhage
   • Endometritis
   • Retained placental fragments requiring subsequent intervention 2

3. Prepare for hemorrhage: Have blood products available and be ready to deploy massive transfusion protocol if needed, especially in preterm cases with risk factors for retained placenta 2