What is the management for a patient with retained placenta and significant bleeding, specifically considering aortic compression?

Management of Retained Placenta with Significant Bleeding

Immediate Resuscitation and Hemorrhage Control

For a patient with retained placenta and significant bleeding, aortic compression is NOT a standard or recommended intervention; instead, immediate management should focus on bimanual uterine compression, uterotonic administration, and preparation for manual removal of the placenta under adequate analgesia. 1, 2

Initial Stabilization Steps

• Administer oxytocin 5-10 IU slow IV or intramuscular injection immediately alongside fluid resuscitation with physiologic electrolyte solutions 1
• Implement bimanual uterine compression by placing a fist inside the vagina against the anterior lower uterine segment while applying counter-pressure with the other hand on the abdomen 1
• Initiate uterine massage as an immediate non-pharmacological intervention 1
• Maintain patient warmth, as clotting factors function poorly at lower temperatures 1

Tranexamic Acid Administration

Administer tranexamic acid (TXA) 1 g intravenously at 1 mL/min (over 10 minutes) within 3 hours of birth, as delay reduces benefit by approximately 10% for every 15 minutes 1. This is a critical time-sensitive intervention that should not be delayed.

• A second dose of 1 g should be administered if bleeding continues after 30 minutes or restarts within 24 hours 1
• TXA is contraindicated in women with a known thromboembolic event during pregnancy 1

Definitive Management of Retained Placenta

Manual Removal

Manual removal of the placenta should be performed at 30-60 minutes postpartum with adequate analgesia 3. This is the definitive treatment for retained placenta and should not be delayed if significant hemorrhage is present 2, 4.

• If hemorrhage is significant, manual removal should be performed earlier than 30 minutes 2, 4
• Ensure adequate analgesia is provided before attempting manual removal 2
• When creating a separation plane between placenta and uterus is particularly difficult, consider placenta accreta spectrum and prepare for potential hemorrhage and hysterectomy 2

Medical Adjuncts (Limited Efficacy)

While medical management alone has not been proven effective for retained placenta 2, certain adjuncts may reduce the need for manual removal:

• Intraumbilical oxytocin (30 IU in 30 mL saline) can reduce the need for manual removal by 20% 3 and has shown significant reduction in manual removal rates (30% vs 67.7%) 5
• Systemic uterotonics (sulprostone or misoprostol) may result in little to no difference in manual removal rates compared to placebo 6

Massive Hemorrhage Protocol

If blood loss exceeds 1500 mL, initiate massive transfusion protocol with packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio 1.

Escalating Interventions for Ongoing Hemorrhage

• Implement intrauterine balloon tamponade if pharmacological management fails 1
• Perform uterine evacuation with suction curettage under ultrasound guidance if retained products remain 4
• Consider pelvic pressure packing for acute uncontrolled hemorrhage, which may be left in for 24 hours 1
• Interventional radiology for arterial embolization should be considered when no single source of bleeding can be identified 1

Surgical Options as Last Resort

• Uterine compression sutures 1
• Uterine or internal iliac artery ligation 1
• Hysterectomy if bleeding continues despite all other measures 1

Critical Pitfalls to Avoid

• Do NOT delay treatment for active hemorrhage while waiting for laboratory results 1
• Do NOT delay TXA administration, as effectiveness decreases by 10% for every 15 minutes of delay 1
• Do NOT confuse retained placenta with placenta accreta spectrum, which requires specialized multidisciplinary planning 7
• Do NOT use methylergonovine in hypertensive patients due to vasoconstriction risk 1
• Do NOT allow hypothermia or acidosis to develop, as these impair clotting function 1

Monitoring and Follow-up

• Continue hemodynamic monitoring for at least 24 hours after delivery 1
• Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 1
• Consider prophylactic antibiotics with manual placenta removal, though evidence is inconsistent 2

Note on Aortic Compression: Aortic compression is not mentioned in current guidelines for retained placenta management. The evidence-based approach prioritizes bimanual uterine compression, uterotonics, and timely manual removal as the standard of care for this specific clinical scenario.