An Appraisal of Retained Placenta in Sokoto

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Retained Placenta in Sokoto Orient Journal of Medicine Vol 25 [1-2] Jan-Jun, 2013

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ORIGINAL ARTICLE

An Appraisal of Retained Placenta in Sokoto: a five-year review

Sununu T YUSUF1Abubakar A PANTI2Daniel C NNADI2

Departments of Obstetricsand Gynaecology of:1Federal Medical CentreBirnin Kebbi, NIGERIA2Usmanu DanfodiyoUniversity Teaching HospitalSokoto, NIGERIA

Author for CorrespondenceYusuf Tanko SUNUNUDept of Obstetrics and

GynaecologyFederal Medical CentreBirnin Kebbi, NIGERIA

E-mail: [email protected]: +2348032611059

Received: January 31st, 2013Accepted: April 23rd, 2013

_____________________

ABSTRACT_________________________________________________________Background: Retained placenta is one of the major causes of primaryand secondary postpartum haemorrhage associated with increased risk

of maternal morbidity and mortality.Objective: To determine the incidence, method of treatment andmaternal outcome of patients with retained placenta.Methodology:This is a retrospective study covering a period of 5years,January 1st, 2007 to December 31st, 2011, in Usmanu DanfodiyoUniversity Teaching Hospital (UDUTH), Sokoto.Results: During the 5-year period, there were 144 cases of retainedplacenta out of 8569 total deliveries, giving an incidence of 1.7%.However, only 118 patients case records were available for analysis.Majority of the patients 88 (74.6%) were unbooked for antenatal care inUDUTH and 104 (88.1%) patients had home delivery. The identified riskfactors included previous history of retained placenta 32 (27.1%) and

previous uterine surgery 13 (11.0%). Fifty per cent of the patients were inhypovolaemic shock at presentation. Manual removal of the placentawas the most common mode of treatment 91 (77.1%). There were 7maternal deaths giving a case fatality rate of 5.9%.Conclusion: Retained placenta is a significant cause of maternalmortality and morbidity due to the associated haemorrhage and othercomplications related to its removal. Antenatal care, skilled birthattendant at delivery and provision of emergency obstetrics care serviceswill help to reduce the incidence and severity.

Keywords:Morbidity, mortality, post-partum haemorrhage, Sokoto

INTRODUCTIONRetained placenta is a common cause ofpostpartum haemorrhage1, a condition thataffects between 0.6 and 3.3% of normaldeliveries.2,3,4 A placenta is retained whenmethods designed to deliver it fail. Withactive management of the third stage oflabour, no time limit needs to be exceededbefore arriving at the diagnosis.5 However,other authors have quoted a time of 30minutes because it is within this time that95% of the placenta would have been

delivered.6Also, once the third stage exceeds30minutes, there is a 10-fold increase in therisk of haemorrhage.7

Retained placenta is a significant cause ofmaternal morbidity and mortality throughoutthe developing world and has a case fatalityof nearly 10% in rural areas.8 Failure ofexpulsion of the placenta may be due toatonic uterus, full bladder or mismanagementof the third stage of labour leading to theformation of retraction ring arresting part or
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the entire placenta within the uterine cavity.9Abnormal implantation of placenta, as inplacenta accreta and uterine abnormalitieslike bicornuate uterus, have also beenassociated with placental retention.10 The

majority of cases of retained placenta occurdue to failure of retro placental myometriumto contract during the third stage of labour.8Another cause of retained placenta is itsmorbid adherence to the myometrium. This isfavoured by such factors as previousendometritis, submucous uterine fibroid,placenta praevia, placental malformation(such as extra chorionic placenta) andprevious surgical procedures such asendometrial curettage, manual removal of

placenta, previous caesarean section,myomectomy or intrauterine adhesiolysis.11

Presently, the most common mode oftreatment of retained placenta is manualremoval under general anaesthesia.8 Oxytocininfusion is another mode of treatment andpreoperatively it minimizes bleeding beforethe definitive procedure could be carried outand besides, it may facilitate separation of theplacenta. Injection of oxytocin as 50IU in 30ml

of saline into the umbilical vein has beensuggested as alternative treatment in whichdetachment of placenta usually takes place10-20 minutes after and can be removed bycontrolled cord traction.12 Sequentialadministration of oxytocin and nitroglycerineseems to be an effective and safe procedure inthe management of retained placenta.13

The main complications of retained placentaare primary postpartum haemorrhage and

genital sepsis, while the complications ofmanual removal include incomplete removalof the placenta, uterine perforation, uterineinversion and genital sepsis.7

This study was carried out to determine theincidence, method of treatment and maternaloutcome in patients treated for retainedplacenta.

METHODOLOGYThis is a retrospective study covering a periodof 5 years from January 1st, 2007 to December

31st, 2011. The study population consisted ofwomen who were managed for retainedplacenta after 28weeks of gestation during theperiod of study at Usmanu DanfodiyoUniversity Teaching hospital (UDUTH),

Sokoto, Nigeria. Relevant data were retrievedfrom the case notes of the study subjects,labour ward records and operating theatreregister. Only the case records of 118 wereretrieved from the Medical RecordsDepartment and 26 case records could not betraced. The relevant data from retrieved casenotes were collated and analyzed using SPSSversion 11.

RESULTS

There were 144 cases of retained placenta outof 8,569 total deliveries during the period ofstudy, giving the incidence of retainedplacenta as 1.7%. Their age, parity, occupationand educational status are shown on Table 1.

Table1. Socio-demographic characteristics

Variables Number (%)N = 118

Age (years)


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paid employment, whereas 70% had noformal education. Unbooked patients (thosewho did not benefit from ante natal care)constituted 74.6% of the subjects, whilebooked patients (those who benefited from

antenatal care) accounted for 25.4%. Majorityof patients (85.6%) had unsupervised deliveryat home as in Table 2.

Table 2. Identified risk factors for retainedplacenta

Variables Number (%)N= 118

Home deliveryPrevious history of

retained placentaPrevious uterine surgeryPreterm deliveryPrevious dilatation andcurettage

101 (85.6)32 (27.1)

13 (11.0)10 (8.5)

9 (7.6)Note that some patient had more than one riskfactor

Previous history of retained placenta wasfound in 32 (27.1%) patients, while 13 (11.0%)patients had history of uterine surgery and 10

(8.5%) patients had preterm deliveries. Sixty-two (52.5%) patients were in circulatorycollapse (shock) at presentation, and atadmission 39 (33.0%) had severe anaemia.

Table 3. Mode of removal of retained placenta

Variables Number (%)N=118

Manual removalControlled cord traction

Oxytocin injection viaumbilical veinHysterectomyOxytocin infusionUterine evacuation

91(77.1)10 (8.5)

5 (4.2)

4 (3.4)4 (3.4)4 (3.3)

Table 3 shows the methods of removal ofretained placenta that were employed.Manual removal of placenta was done in 91(77.1%) patients, controlled cord traction 10(8.5%), oxytocin injection via umbilical veincatheterization 4 (4.2%) patients and

hysterectomy 4 (4.2%) patients. Of the 91(77.1%) patients that had manual removal, 40(44.0%) had it done under sedation while 21(23.0%) patients had manual removal doneunder general anaesthesia. All the patients

presenting with retained placenta wereplaced on antibiotics.

Table 4. Blood transfusion

Number of units transfusedper patient

Number ofpatients (%)

N = 118

012

34 or more

55 (46.6)5 (4.2)18 (15.3)

17 (14.4)23 (19.5)

Table 4 shows the number of units of bloodtransfused to the patients. Fifty five patients(46.6%) did not receive blood transfusion, 5(4.2%) patients received 1 unit of blood eachwhile 18 (15.3%) were transfused with 2 unitsof blood each. Seventeen (14.4%) patientswere transfused with 3 units of blood each,while 23 patients were transfused with 4 or

more units of blood each. There were 7maternal deaths giving a case fatality rate of5.9%.

DISCUSSIONPostpartum haemorrhage due to retainedplacenta is a major cause of maternalmorbidity and mortality. The incidence ofretained placenta in this study was 1.7%. Thiswas similar to findings in the previousreports where it ranged between 0.6 and

3.3%.2,3,4,14,15,16,17The mean age of presentationwas 27.55 7.41 with majority of the patientswithin 20 to 29years range. Only 10% of thepatients were employed which was far lowerthan 90% reported in South-westernNigeria.15 Unbooked patients constitutedmajority of the cases, which corroboratesreports from Ibadan and Ile Ife, South-western Nigeria.14,15

Delivery by unskilled personnel is more

prone to complications of third stage oflabour, leading to increased incidence of


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retained placenta in the patients who werenot booked for antenatal care. Non-bookingfor antenatal care apparently ledapproximately to 25-fold increase in incidenceof retained placenta in this study. The

significant number of unbooked cases in thisenvironment is attributed to non-utilization ofhealth care services probably because ofpoverty and ignorance.

Predisposing factors to retained placentaobserved in this study included homedelivery, previous history of retainedplacenta, previous uterine surgery, pretermdelivery and previous dilatation andcurettage which had also been documented

by previous authors.14,15,16 The study alsoshowed that 52.5% patients were in a state ofshock at presentation. This figure was higherthan the 42% at Ile-Ife, Western Nigeria.18This may be due to the fact that majority ofour patients present late compared to those atIle-Ife.

Anaemia was observed at admission in mostof the patients, correlating with the reportfrom Ibadan, and other places like that of by

Onwuidiegwu and Makinde.14,18 Probably,because most of the patients treated by theseother authors presented earlier in theirsettings, they had less blood loss compared tothose in our study.

Fifty-three per cent of the patients weretransfused which was higher than 38.8%reported in Ibadan.14 Twenty-three patientswere transfused with 4 or more units ofblood. However, this figure was lower than

what was reported from Ile-Ife.18The attemptat blood replacement was inadequate as78.3% of the patients still remained anaemicat discharge. This finding was, however,higher than 53% reported in similar study inSouth-western Nigeria.18This difference maybe attributed to the higher degree of bloodloss in our study and also, the financialconstraints due to poverty since almost all thepatients in this study were not gainfullyemployed.

Retained placenta was treated with manualremoval in 77.1% of the cases during thestudy period, which was less than 90% in Ile-Ife.18 This wide difference is due to latepresentation and poor haemodynamic status

at presentation in our study which obviatedthe need for manual removal and informedthe choice of other modalities of removal.Majority of patients in this study as in thestudy in Ile-Ife had manual removal ofplacenta done under sedation with diazepamand pethidine. This led to a reduction in thecost of treatment when compared to the useof general anaesthesia, which is veryimportant in our environment where the vastmajority of them live below the poverty line.

A case fatality rate of 5.9% in this study wasmuch higher than 1% reported in Ile-Ife,South-western Nigeria.18 This fatality ratemay be due to severe blood loss, latepresentation and failure to attend antenatalcare, which was relatively commoner in ourstudy subjects.

CONCLUSIONRetained placenta is a significant cause of

maternal mortality and morbidity due to theassociated haemorrhage, and othercomplications related to its removal. Optimalantenatal care, skilled birth attendant duringdelivery and provision of emergency obstetriccare services will help to reduce the incidenceand severity of retained placenta.

REFERENCES1. Endler M, Grunewald C, Satvedt S.

Epidemiology of retained placenta, oxytocin

as an independent risk factor. Obstet Gynaecol2012; 119:801-809.

2. Cheung WM, Hauker A, Ibish S, Weeks AD.The retained placenta. Historical andgeographical rate variations. J Obstet Gynaecol2011; 31:37-42.

3.

Combs CA and Laros RK.Prolong third stageof labour: morbidity and risk factors. ObstetGynaecol 1991; 77:862867.

4. Tandberg A, Albrechtsen S and Iverson OE.Manual removal of placenta. Acta ObstetGynaecol Scand1999; 78:3336.

5.

Beazley JM. Complication of 3rd stage oflabour. In: Whitfield CR (Ed) Dehursts


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An Appraisal of Retained Placenta in Sokoto