What is the management for a retained placenta with a contracted uterus?

Management of Retained Placenta with Contracted Uterus

For a retained placenta with a contracted uterus (placenta adherens), manual removal under anesthesia remains the definitive treatment at 30-60 minutes postpartum, but intraumbilical oxytocin injection (30 IU in 30 mL saline) can reduce the need for manual removal by approximately 20% and should be attempted first. 1

Understanding the Pathophysiology

A contracted uterus with retained placenta indicates placenta adherens—failed contraction of the retro-placental myometrium preventing placental separation, rather than a trapped placenta (which involves cervical constriction) or placenta accreta (abnormal placental invasion). 2, 1 This distinction is critical because the treatments differ fundamentally:

• Placenta adherens requires uterotonics to contract the retro-placental myometrium 2
• Trapped placenta requires uterine relaxants (nitroglycerin or terbutaline) to resolve cervical constriction 3, 4
• Administering uterotonics systemically for placenta adherens can paradoxically worsen a trapped placenta by increasing cervical tone 2

Initial Medical Management (Before 30 Minutes)

Intraumbilical Oxytocin Injection

• Administer 30 IU oxytocin in 30 mL saline via umbilical vein injection as first-line medical therapy 1
• This approach may reduce the need for manual removal by approximately 20% 1
• Low-certainty evidence suggests oxytocin solution via umbilical vein might slightly reduce manual removal compared to expectant management (RR 0.73,95% CI 0.56 to 0.95) 5
• The mechanism bypasses systemic circulation and delivers oxytocin directly to the retro-placental myometrium 2

Timing Considerations

• Do not attempt manual removal before 30 minutes postpartum unless severe uncontrollable hemorrhage occurs 3, 1
• The World Health Organization defines retained placenta as failure of spontaneous delivery more than 30 minutes after fetal expulsion 3
• Manual removal should be performed at 30-60 minutes postpartum if medical management fails 1

Definitive Management: Manual Removal

Anesthetic Approach

If an epidural catheter is already in place and the patient is hemodynamically stable, epidural anesthesia is the preferred technique for manual removal. 3

• Neuraxial anesthesia (epidural or spinal) is first-line when the patient is hemodynamically stable 3, 6
• Assess hemodynamic status thoroughly before administering neuraxial anesthesia—check for active bleeding, blood pressure stability, and signs of hypovolemia 3, 6
• Aspiration prophylaxis should be considered due to increased aspiration risk in the immediate postpartum period 3

When General Anesthesia is Preferred

In cases involving major maternal hemorrhage with hemodynamic instability, general anesthesia with endotracheal intubation is preferable to neuraxial anesthesia. 3, 6

• Major hemorrhage (>1000 mL or hemodynamic instability) is an indication for general anesthesia 3
• Have ephedrine readily available to treat hypotension during any anesthetic technique 4

Uterine Relaxation (If Needed)

If the uterus remains contracted and prevents manual removal despite anesthesia:

Administer nitroglycerin in incremental IV doses of 50-100 mcg boluses or sublingual spray to achieve uterine relaxation while minimizing hypotension. 3, 4

• Nitroglycerin is an alternative to terbutaline or halogenated general anesthetic agents for uterine relaxation 3, 4
• Monitor blood pressure continuously during administration 4
• This is a critical distinction: uterine relaxation is only needed if the contracted uterus prevents access during manual removal, not as primary treatment for placenta adherens 3

Postpartum Hemorrhage Prevention

Active Management of Third Stage

• Administer 5-10 IU oxytocin slow IV or IM at time of shoulder release or immediate postpartum to reduce PPH incidence 3
• Active management (prophylactic uterotonics, controlled cord traction after placental separation) reduces PPH risk compared to expectant management (RR 0.38,95% CI 0.32 to 0.46) 3

If Hemorrhage Occurs

• Administer 1 g tranexamic acid IV within 1-3 hours of bleeding onset to reduce bleeding-related mortality 3
• Methylergonovine can be used for routine management of uterine atony and hemorrhage following placental delivery 7

Critical Pitfalls to Avoid

1. Do not attempt forced placental removal without anesthesia—this causes profuse hemorrhage and is strongly discouraged 3
2. Do not administer systemic uterotonics if you suspect trapped placenta (cervical constriction)—this worsens the condition 2
3. Do not delay manual removal beyond 60 minutes unless the patient is stable and medical management is showing progress 1
4. Do not use neuraxial anesthesia in hemodynamically unstable patients—general anesthesia is safer 3, 6
5. Do not confuse the need for uterine relaxation during manual removal with primary treatment—a contracted uterus with retained placenta needs oxytocics first, not relaxants 2

Evidence Limitations

Current evidence for systemic uterotonics (sulprostone, misoprostol) versus placebo shows they may result in little to no difference in manual removal rates (RR 0.82,95% CI 0.54 to 1.27), PPH, or blood transfusion requirements 8. The most promising intervention remains intraumbilical oxytocin, though evidence is low-certainty 5. Manual removal remains the gold standard when medical management fails 1.