How do I diagnose and manage retained placental tissue in a postpartum patient without access to radiological investigations?

Diagnosing and Managing Retained Placental Tissue Without Radiological Access

In the absence of ultrasound or other imaging, you must rely on clinical diagnosis based on history, physical examination findings, and response to initial management—specifically looking for failure of placental delivery within 30-60 minutes, ongoing hemorrhage, or incomplete placental examination. 1, 2

Clinical Diagnosis Without Imaging

Key Historical Risk Factors to Identify

• Prior cesarean delivery or uterine surgery (highest risk for placenta accreta spectrum) 1
• History of retained placenta in previous pregnancies 1
• Prolonged oxytocin use during labor 1
• High parity, preterm delivery, or IVF conception 1
• Congenital uterine anomalies 1

Critical Physical Examination Findings

• Timing: Placenta not delivered spontaneously within 30-60 minutes postpartum 2
• Active hemorrhage: Significant bleeding before placental delivery warrants immediate intervention regardless of time elapsed 1
• Incomplete placenta on examination: Careful inspection of the delivered placenta for missing cotyledons or torn membranes 1
• Palpable uterine mass: Boggy, enlarged uterus that fails to contract adequately 1

Immediate Management Algorithm

Step 1: Hemodynamic Assessment

• If hemodynamically unstable with heavy bleeding: Proceed immediately to manual removal while simultaneously initiating massive transfusion protocol 3, 1
• If stable: Proceed with systematic approach below 1

Step 2: Initial Medical Intervention (Before Manual Removal)

• Administer intraumbilical oxytocin: 30 IU in 30 mL saline can reduce need for manual removal by 20% 2
• For suspected trapped placenta: Give glyceryl trinitrate 500 mcg sublingually to relax the cervix, followed by gentle controlled cord traction 2
• Wait 30-60 minutes maximum before proceeding to manual removal 2

Step 3: Manual Removal of Placenta

• Ensure adequate analgesia before attempting manual removal 1
• Technique: Insert hand into uterine cavity, identify plane between placenta and uterine wall, and systematically separate placenta using side of hand 1, 2
• Critical warning sign: If you cannot create a separation plane easily, suspect placenta accreta spectrum and prepare immediately for hemorrhage and possible hysterectomy 1

Step 4: Post-Removal Assessment

• Carefully examine all removed tissue to ensure completeness 1
• Send tissue for pathologic examination, particularly if there was difficulty with removal or risk factors for accreta 4
• Look for basal plate myometrial fibers (BPMF) on pathology, as this indicates increased risk (up to 35-fold) for placenta accreta in subsequent pregnancies 4, 3

Management of Complications Without Imaging

Hemorrhage Management

• Immediate uterine evacuation with suction to remove any remaining tissue or clots 1
• Intrauterine balloon tamponade (Bakri balloon or equivalent) 1
• Massive transfusion protocol activation 1
• If bleeding continues despite these measures: Proceed to surgical intervention (uterine artery ligation, B-Lynch suture, or hysterectomy) 1

Suspected Incomplete Removal

Clinical indicators without ultrasound:

• Persistent bleeding beyond expected postpartum course 3
• Uterine tenderness and fever suggesting endometritis 1
• Failure of uterus to involute normally on serial abdominal examinations 5
• Persistent elevated or rising beta-hCG levels if available 3, 6

Management approach:

• Consider prophylactic antibiotics after manual removal, though evidence is inconsistent 1
• If infection suspected: Broad-spectrum antibiotics covering endometritis 1
• If persistent bleeding: Repeat uterine curettage may be necessary, but proceed cautiously as this increases risk of Asherman syndrome 1

Critical Pitfalls to Avoid

Placenta Accreta Spectrum Recognition

• Do not persist with aggressive manual removal if a separation plane cannot be established—this indicates possible accreta and risks catastrophic hemorrhage 1
• Patients with anterior placenta previa and prior cesarean delivery have up to 40% risk of accreta 4
• In accreta cases without imaging diagnosis: Be prepared for immediate hysterectomy 1

Delayed Presentation

• Retained placental tissue can present days to years later as placental polyp with bleeding and positive pregnancy test 6
• Without ultrasound for follow-up: Rely on clinical involution assessment and beta-hCG trends if available 3, 6

Documentation for Future Pregnancies

• Document all details of manual removal difficulty and send placenta for pathology 4
• If BPMF stage 2 or 3 found on pathology: Patient requires close monitoring in subsequent pregnancies for placenta accreta spectrum 4, 3

Conservative Management Considerations

Medical management alone (without manual removal) is NOT effective for true retained placenta and should not be attempted 1. The only medical adjuncts that may help are intraumbilical oxytocin and glyceryl trinitrate as temporizing measures before manual removal 2.