At 16 weeks gestation, how long can I wait for placental expulsion after fetal delivery, and is a blood loss of 1 liter an indication for immediate suction dilation and curettage (D&C) in the operating room (OR)?

Management of Retained Placenta at 16 Weeks Gestation

For a 16-week placenta, manual removal should not be performed unless there is severe and uncontrollable postpartum hemorrhage, and a blood loss of 1 liter is an indication for immediate suction D&C in the operating room. 1

Timing of Placental Expulsion

• The World Health Organization defines retained placenta as spontaneous placental delivery occurring more than 30 minutes after fetal expulsion 1
• For a 16-week gestation, there is no specific literature on the recommended time interval between fetal expulsion and placental delivery 1
• Recent observational data suggests an increased risk of postpartum hemorrhage >500 mL when spontaneous placental delivery occurs more than 30 minutes after fetal expulsion 1
• However, postpartum blood loss does not directly correlate with third stage duration in women with retained placenta, suggesting there is no absolute safe time window 2

Management Algorithm

Initial Management (0-30 minutes post-delivery):

• Administer 5-10 IU of oxytocin via slow IV or intramuscular infusion immediately after fetal delivery to reduce incidence of postpartum hemorrhage 1
• Allow for spontaneous placental expulsion without manual intervention 1
• Monitor blood loss carefully using calibrated collection methods 2

If Placenta Remains Retained (30-60 minutes):

• Continue expectant management with close monitoring of bleeding 1
• Do not perform manual removal of the placenta to reduce risk of postpartum hemorrhage unless severe bleeding occurs 1
• Consider transfer to a specialized facility if not already in one 1

For Significant Hemorrhage:

• If blood loss approaches or reaches 1 liter, this constitutes severe postpartum hemorrhage and requires immediate intervention 1
• Proceed to operating room for suction D&C when blood loss reaches 1 liter 1
• Administer 1g of tranexamic acid IV within 1-3 hours of bleeding onset to reduce maternal morbidity and mortality 1
• Implement massive transfusion protocol if needed 1
• Keep patient warm (>36°C) as clotting factors function poorly at lower temperatures 1
• Avoid acidosis 1
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio for acute hemorrhage 1

Special Considerations

• Uterine atony significantly increases the risk of hemorrhage and need for blood transfusion, regardless of the duration of the third stage 2
• The prompt detection of uterine atony is a key factor in managing postpartum hemorrhage 2
• Laboratory testing (platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels) is critical for hemorrhage management 1
• Treat based on clinical presentation initially without waiting for laboratory results 1

Pitfalls and Caveats

• Manual removal of the placenta should be avoided except in cases of severe and uncontrolled hemorrhage due to potential technical difficulties and risks of infection 1
• A shorter third stage (<60 minutes) with retained placenta can be associated with significantly increased uterine atony and need for blood transfusion 2
• There is no evidence supporting a specific "safe" time window before postpartum hemorrhage occurs with retained placenta 2
• Have a low threshold for reoperation if there is suspected ongoing bleeding after initial management 1
• Consider the possibility of placenta accreta spectrum if a separation plane between the placenta and uterus is particularly difficult to create 3