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Retained Placenta and Postpartum Haemorrhage
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim was to explore the possibility to diagnose retained placental tissue and other placental complications with 3D ultrasound and to investigate the impact of previous caesarean section on placentation in forthcoming pregnancies.

3D ultrasound was used to measure the volumes of the uterine body and cavity in 50 women with uncomplicated deliveries throughout the postpartum period. These volumes were then used as reference, to diagnose retained placental tissue in 25 women with secondary postpartum haemorrhage. All but three of the 25 women had retained placental tissue confirmed at histopathology. The volume of the uterine cavity in women with retained placental tissue was larger than the reference in most cases, but even cavities with no retained placental tissue were enlarged (Studies I and II).

Women with their first and second birth, recorded in the Swedish medical birth register, were studied in order to find an association between previous caesarean section and retained placenta. The risk of retained placenta with heavy bleeding (>1,000 mL) and normal bleeding (≤1,000 mL) was estimated for 19,459 women with first caesarean section delivery, using 239,150 women with first vaginal delivery as controls. There was an increased risk of retained placenta with heavy bleeding in women with previous caesarean section (adjusted OR 1.61; 95% CI 1.44-1.79). There was no increased risk of retained placenta with normal bleeding (Study III).

Placental location, myometrial thickness and Vascularisation Index were recorded on 400 women previously delivered by caesarean section. The outcome was retained placenta and postpartum haemorrhage (≥1,000 mL). There was a trend towards increased risk of postpartum haemorrhage for women with anterior placentae. Women with placenta praevia had an increased risk of retained placenta and postpartum haemorrhage. Vascularisation Index and myometrial thickness did not associate (Study IV).

In conclusion: 3D ultrasound can be used to measure the volume of the uterine body and cavity postpartum, but does not increase the diagnostic accuracy of retained placental tissue. Previous caesarean section increases the risk of retained placenta in subsequent pregnancy, and placenta praevia in women with previous caesarean section increases the risk for retained placenta and postpartum haemorrhage.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 59 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1077
Keyword [en]
postpartum haemorrhage, retained placenta, secondary postpartum haemorrhage, retained placental tissue, threedimensional ultrasound, previous caesarean section
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:uu:diva-246185ISBN: 978-91-554-9182-6 (print)OAI: oai:DiVA.org:uu-246185DiVA: diva2:792274
Public defence
2015-04-23, Rosénsalen, Ing 95/96, Akademiska sjukhuset, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2015-04-02 Created: 2015-03-03 Last updated: 2015-04-17
List of papers
1. Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium
Open this publication in new window or tab >>Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium
2012 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 10, 1184-1190 p.Article in journal (Refereed) Published
Abstract [en]

Objective.

To describe uterine involution in the puerperium with three-dimensional ultrasound.

Design.

Prospective, longitudinal study.

Setting.

Fetal medicine unit, department of obstetrics and gynecology, university referral hospital, Uppsala, Sweden.

Population.

Fifty women with uncomplicated deliveries and puerperium between February 2009 and February 2010.

Methods.

Three-dimensional ultrasound was used to measure the uterine body and cavity volumes. The volume data set was analysed using virtual organ computer-aided analysis (VOCAL) with a 30 degree rotation step. Measurements were performed transabdominally on days 1, 7 and 14 and transvaginally on days 28 and 56 postpartum. Parity, gestational age, birthweight, smoking, breastfeeding and blood loss were recorded.

Main outcome measures.

Uterine body and cavity volumes. Results. Median uterine body volume was 756 cm3 on day 1, 440 cm3 on day 7, 253 cm3 on day 14, 125 cm3 on day 28 and 68 cm3 on day 56. Median cavity volume was 22 cm3 on day 1, 18 cm3 on day 7, 6 cm3 on day 14, 1 cm3 on day 28 and not measurable on day 56. The interindividual variation of uterine body and cavity volumes was most pronounced on day 1 and decreased throughout the observation period. Intrauterine content was found in 36% of the women on day 1, 95% on day 7, 87% on day 14 and 28% on day 28.

Conclusions.

Three-dimensional ultrasound is a non-invasive tool suitable for measurement of the uterine body and cavity volumes during the puerperium. The volumes decreased in a similar pattern in the study population.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-182446 (URN)10.1111/j.1600-0412.2012.01418.x (DOI)000308887300009 ()22497320 (PubMedID)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2017-12-07Bibliographically approved
2. Three-dimensional ultrasound does not improve diagnosis of retained placental tissue compared to two-dimensional ultrasound
Open this publication in new window or tab >>Three-dimensional ultrasound does not improve diagnosis of retained placental tissue compared to two-dimensional ultrasound
2015 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 1, 112-116 p.Article in journal (Refereed) Published
Abstract [en]

The study objective was to improve ultrasonic diagnosis of retained placental tissue by measuring the volume of the uterine body and cavity using three-dimensional (3D) ultrasound. Twenty-five women who were to undergo surgical curettage due to suspected retained placental tissue were included. The volume of the uterine body and cavity was measured using the VOCAL imaging program. Twenty-one women had retained placental tissue histologically verified. Three of these had uterine volumes exceeding the largest volume observed in the normal puerperium. Seventeen of the 21 women had a uterine cavity volume exceeding the largest volume observed in the normal puerperium. In all 14 cases examined 28 days or more after delivery the cavity volume exceeded the largest volume observed in the normal puerperium. A large cavity volume estimated with 3D ultrasound is indicative of retained placental tissue. However, 3D ultrasound adds little or no diagnostic power compared to 2D ultrasound.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-240535 (URN)10.1111/aogs.12502 (DOI)000346704100019 ()25303033 (PubMedID)
Available from: 2015-01-07 Created: 2015-01-07 Last updated: 2017-12-05Bibliographically approved
3. Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.
Open this publication in new window or tab >>Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.
Show others...
2014 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 121, no 2, 224-229 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery.

DESIGN: Population-based cohort study.

SETTING: Sweden.

POPULATION: All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258 608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population.

METHODS: The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19 458), using women with a first vaginal delivery as reference (n = 239 150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics.

MAIN OUTCOME MEASURES: Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding.

RESULTS: The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79).

CONCLUSIONS: Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-214810 (URN)10.1111/1471-0528.12444 (DOI)000328863800017 ()24044730 (PubMedID)
Available from: 2014-01-09 Created: 2014-01-09 Last updated: 2017-12-06Bibliographically approved
4. Placental location, postpartum haemorrhage and retained placenta in women previously delivered by caesarean section: a prospective cohort study
Open this publication in new window or tab >>Placental location, postpartum haemorrhage and retained placenta in women previously delivered by caesarean section: a prospective cohort study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective The objective was to determine if anterior placental location increased the risk of postpartum haemorrhage (PPH) and retained placenta in women previously delivered by caesarean section.

 

Design Prospective cohort study.

 

Setting Fetal medicine unit, Uppsala University hospital, Sweden.

Population. Four hundred women previously delivered by caesarean section.

Methods Ultrasound scans were performed at gestational week 28-30. Placental location, myometrial thickness and three-dimensional vascularisation index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, Oxytocin, preeclampsia, PPH, retained placenta and birth weight was obtained.

Main Outcome Measures PPH (≥ 1000 ml) and retained placenta.

Results Twenty-four women (11.6%) of 213 with anterior placentas had PPH compared to 13 (7.3%) with placentas in other locations. This difference was not significant. No significant risk increase was found for retained placenta in women with anterior placentae. Of the 23 women with low anterior placentae six (26.1%) had PPH compared to 38 (10.3%) with other placental locations (p = 0.032). Three women (13.0%) with low anterior placentae had retained placenta compared to 11 (2.9%) with other locations (p = 0.04). All women but one with low-lying anterior placentae and PPH and all with retained placentae had placenta praevia.

Conclusion Low anterior placentae in women previously delivered by caesarean section increased the risk of PPH and retained placenta, mostly due to placenta praevia. Other anterior locations of the placenta may add to the increased risk of PPH. 

National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-246178 (URN)
Available from: 2015-03-03 Created: 2015-03-03 Last updated: 2015-04-17

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