What is the management of placenta after a 12-week delivery?

Management of Placenta After 12-Week Delivery

For a 12-week delivery, expectant management of the placenta is recommended, with manual removal only indicated in cases of severe, uncontrollable hemorrhage. 1

Initial Management Approach

Expectant Management

• Allow for spontaneous placental delivery without manual intervention
• Monitor for signs of placental separation (small gush of blood, cord lengthening)
• The World Health Organization defines retained placenta as spontaneous placental delivery not occurring within 30 minutes after fetal expulsion 1

Pharmacological Management

• Administer oxytocin 5-10 IU slow IV or intramuscular injection immediately after delivery to reduce the risk of postpartum hemorrhage 1
• Avoid methylergonovine (Methergine) as it carries risk (>10%) of vasoconstriction and hypertension 1, despite its FDA approval for routine management after placental delivery 2, 3

When to Consider Manual Removal

Manual removal of the placenta should not be routinely performed at 12 weeks gestation except in the following circumstances:

• Severe and uncontrollable hemorrhage 1
• No signs of placental separation after 30-60 minutes with active bleeding

Alternative Approaches Before Manual Removal

If the placenta remains retained after 20-30 minutes:

1. Intraumbilical Oxytocin:

   • Consider intraumbilical vein injection of oxytocin (20 IU in 20 mL saline) 4, 5
   • This approach has shown significant reduction in the need for manual removal (30% vs 67.7%) 5
   • Studies demonstrate increased spontaneous expulsion of placenta within 45-60 minutes after injection 4, 6

2. Controlled Cord Traction:

   • Apply gentle traction on the umbilical cord while providing counter-pressure on the uterus
   • Avoid excessive force which could cause cord avulsion or uterine inversion

Monitoring During Third Stage

• Monitor vital signs closely
• Observe for excessive bleeding (>500 mL is considered postpartum hemorrhage)
• Position patient in lateral decubitus position to attenuate hemodynamic impact 1

Management of Complications

If Hemorrhage Occurs:

• Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset to reduce maternal morbidity and mortality 1
• Ensure IV access and availability of blood products if needed
• Prostaglandin F analogues can be used to treat postpartum hemorrhage unless increase in pulmonary artery pressure is undesirable 1

Special Considerations

For patients at 12 weeks gestation, the risk of placenta accreta spectrum is extremely low unless there is a history of prior cesarean deliveries or uterine surgeries 7. However, if placenta accreta is suspected:

• Pause the procedure
• Alert anesthesia team
• Obtain additional IV access
• Order blood products
• Consider transfer to a higher level of care if available 7

Pitfalls and Caveats

1. Avoid routine manual removal - This increases the risk of infection, trauma, and hemorrhage
2. Don't delay intervention for severe bleeding - While expectant management is preferred, prompt action is needed for heavy bleeding
3. Be cautious with oxytocin dosing - Higher doses (80 units) may decrease the need for additional treatment but standard doses (10 units) are typically sufficient 8
4. Remember the physiological mechanism - The primary mechanism to stem bleeding from the placental bed is sustained myometrial contraction, not the hemostatic system 1

By following this approach, you can minimize maternal morbidity while appropriately managing the placenta after a 12-week delivery.